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Risk Management for Needles (EN14971:2012)

  • 1.  Risk Management for Needles (EN14971:2012)

    Posted 05-Mar-2013 06:04
    Your opinion please!
    We are a manufacturer of needles. We do have a great variety of different types of needles for all kind of applications.
    Considering the correct application of risk management (with special focus on EU legislation and EN 14971:2012) are we now in a situation where we should withdraw all our needles that do not have inherent safety features from the market?
    Applying risk management would mean: Risk mitigation by inherent design comes first. From my point of view there is a way of including safety features in each and every needle that we have. (Not considering usability at this moment because handling a safety needle is not as easy as a needle without safety features most of the time; but it is safer = lower risk.)

    Looking forward to your input! Many thanks!

    -------------------------------------------
    Florian Tolkmitt
    sfm medical devices GmbH
    Germany
    florian.tolkmitt@sfm.de
    -------------------------------------------


  • 2.  RE:Risk Management for Needles (EN14971:2012)

    Posted 06-Mar-2013 09:01
    It is a bit frustrating to now exclude labeling as a means of risk mitigation.... 

    That being said, don't underestimate the value of your packaging design as a risk mitigation component for your sharps.  The package probably slows the release of the tip relative to the handle, either by a separate protector for the tip or by making the package holder (plastic tray?) for the needle assembly require a pull release for the handle and a sliding release for the tip, such that the pull action must happen before the sliding action.  This is normal needle package design because it is also intuitively helpful for maintaining sterility of the tip.  To further bolster this line of thinking you may want to make sure your "usability test" framework includes a question demonstrating that the user acknowledges that there was no user sharps injury or inadvertent tip contamination action during the opening of the package and subsequent use of the needle.

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    Katharine Stohlman RAC
    Waltham MA
    United States
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  • 3.  RE:Risk Management for Needles (EN14971:2012)

    Posted 07-Mar-2013 11:07
    Florian,

    As I read deviation #5 from Annex ZA it is saying that safety by design and protective measures in the device itself are the favored mitigations by priority.  If you have protective caps on your product they count as mitigation.  You can still claim labeling as further mitigation.  It seems section c of #5 is saying that you don't stop at the cap if that mitigates risk to an acceptable level.  They want you to apply all control options as long as they contribute to product safety.

    This follows As Low As Reasonably Possible (ALARP) thinking on risk mitigation.  With this you do not mitigate until risk is acceptable; you continue mitigate to a reasonable level.  This is still your decision as to what comprises a reasonable level.  Generally I believe it means that going too far with mitigation could add so much to the cost that the product cannot be sold for a reasonable profit.

    I would be interested to hear what others think.

    Regards,

    -------------------------------------------
    John Minier
    Small Bone Innovations, Inc
    Morrisville PA
    United States
    -------------------------------------------








  • 4.  RE:Risk Management for Needles (EN14971:2012)

    Posted 22-Mar-2013 03:32
    Thanks for all the replies provided and for sharing your thoughts.
    I like the way John put it. I understand that the level of risk that is deemed acceptable has to be determined by the manufacturer. However, this is the trouble we are in.

    There is big discussion going on, on the safety aspects of needles in terms of needle stick safety. To my knowledge some states already require needle stick safety devices and prohibit the use on devices that do not have safety features to protect against needlesticks. So can we really determine that a simple cap is safe enough? Can we define, that a cap is our safety feature, when there are guidelines or even laws, that say that a cap is not enough to protect the user, especially after use of the needle.

    Many needles are thrown into safety boxes without beeing protected by any means. This bears a problem in some situations:
    -after use, the needle needs to be transported from the place of operation to the safety box
    ->it might fall down: when picking it up there is a hazard
    ->during transport there is a hazard as well

    Again, I am happy to hear your views on this.
    Many thanks in advance!

    -------------------------------------------
    Florian Tolkmitt
    sfm medical devices GmbH
    Germany
    florian.tolkmitt@sfm.de
    -------------------------------------------








  • 5.  RE:Risk Management for Needles (EN14971:2012)

    Posted 23-Mar-2013 09:34
    We must be careful here.  If the product is not being sold in the EU, the applicable standard is ISO 14971:2007, which is the current international medical device risk management standard.  If the product is being sold in the EU, the recently released EN ISO 14971:2012 is the applicable standard.  The requirements are the same in both standards, and consist of Clauses 1-9 in ISO 14971.  

    The differences are in the informative annexes, ZA for medical devices, ZB for active implantable devices, and ZC for IVDs.  In each of these annexes, CEN (the European standards body) has indicated that compliance with ISO 14971 does not meet the requirements of the directives, and explains the differences.

    Major differences include:

    1.  ALARP may not be used as a risk management policy.  It is not possible to include the use of economics in determining acceptable risk.  

    2.  Each risk must be reduced until it is not possible to reduce the risk anymore.  That is multiple risk controls must be applied until it may be shown (through documentation) that no further risk reduction is possible.

    3.  Information for Use cannot be used to reduce risk.  Information is required to be provided for correct use, it is not a risk control.  Only design for safety or safeguards are allowable risk control measures, and design for safety is the preferable risk control.

    4.  Each risk and the overall risk must have a documented benefit-risk analysis.

    The best information for a manufacturer is provided by their Notified Body.  The Notified Body has been given the responsibility by the directives for allowing devices to be placed on the market.  Many have published documents identifying their expectations for manufacturers in supporting the placing of the device on the market.

    For devices not requiring a Notified Body, a manufacturer can still refer to Notified Body websites for indication on how to meet the requirements of the directives.  

    Remember, the EN ISO 14971:2012 document does not add requirements to ISO 14971, the requirements it discusses are embedded in the directives and have been since the first directives were released.  The 2012 documents were the product of a complaint by a national body, which indicated the harmonized standards (EN ISO 14971and EN ISO 13485) did not meet the requirements of the directives.  And yes, there is a new EN ISO 13485:2012 with explanations of the shortcomings of ISO 13485.  A company should be aware of that revised standard as well, by discussing their quality system with their Notified Body.

    Just to complicate the situation, the directives are being reviewed for revision, and the game may change soon.  Of course a transition period will follow the release of the new directives.  But a word of caution here, the transition period for EN ISO 14971:2012 was one day.

    Getting back to the original question, needle sticks.  This hazardous situation has resulted in many new devices with various approaches to reducing needle sticks.  The use of risk management can lead to a number of different ways to approach the reduction of risk.  The use of a tool such as Fault Tree Analysis (FTA) in the risk management process can show in detail how a needle stick results.  The use of FTA can provide the design team with locations in the process where the risk can be reduced or eliminated in the most efficient and least expensive manner.  And there is not one method, but multiple ways of approaching the problem.  Of course, the use of FTA will require clinical experts in the use of needles to develop an accurate Fault Tree.


    -------------------------------------------
    Edwin Bills RAC
    Principal Consultant
    Bilanx Consulting LLC
    Member, AAMI QM/WG04 Risk Management committee 
    Sumter SC
    United States
    -------------------------------------------








  • 6.  RE:Risk Management for Needles (EN14971:2012)

    Posted 24-Mar-2013 08:54
    This is a great discussion on ISO 14971, but I think it misses the point of the question.  The question was would the risk managment requirment obviate the ability for a company to sell a needle without sharps protection.

    This is a larger, more global question about  user choice and acceptable risk.  Needles (as well a scalpels and other sharp devices) have a risk that is obvious to the user.  Providing a simple, very functional, inexpensive product, with an obvious, known risk, should not be precluded from the market just because there are other alternatives.  If unprotected sharps carry an unaceptable risk, the Compentent authorities have an obligation to ban them to protect the public health - which they have not, and will likely never do.

    The market provides these users with a myriad of choices, some with sharps protection, and some without. Also, there are options that add sharps protection to unprotected sharps, should the user choose to buy them. Also, in this instance, the law with regard to requiring protection applies to the institutions, and forces them to consider the risks and availble controls, amd implement their own policies. 

    I think that when a risk is obvious and undestood, and not legislated as illegal, the choice of a company to provide device that has this obvious risk should not be consdered unacceptable.


    -------------------------------------------
    Lee Leichter RAC
    President
    P/L Biomedical
    Fort Myers FL
    United States
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  • 7.  RE:Risk Management for Needles (EN14971:2012)

    Posted 25-Mar-2013 09:38
    Edwin,

    Just to clarify economics come into play in determining what is "reasonably possible" to mitigate risk.  I agree that economics do not determine what is acceptable risk. Our goal is to provide safe and effective health care.  If we mitigate risk as low as possible without considering economics we could come up with ridiculously expensive methods of risk mitigation that make it no longer profitable to be in business.  At that point we lose the "provide" portion of the goal. 

    It is still up to the company to determine what is acceptable risk compared to the benefit of the product.  This has to be defendable to regulators and in court.  Review by objective medical professionals helps, as does pre-market testing and post-market surveillance.

    Regards,

    John



    -------------------------------------------
    John Minier
    Small Bone Innovations, Inc
    Morrisville PA
    United States
    -------------------------------------------








  • 8.  RE:Risk Management for Needles (EN14971:2012)

    Posted 26-Mar-2013 10:46
    In the EU the final authority is the Notified Body.  You must prove to the Notified Body that you met the requirements of the directive that applies to your device.  The Z Annexes are intended to convey additional requirements (and modified requirements) beyond ISO 14971 to comply with the directives.

    For products that are to be distributed in the EU I always recommend that the manufacturer consult with their Notified Body during the development of the device to determine what requirements the Notified Body will apply and how they expect the manufacturer to apply the requirements.  If you "go it alone" the business risk that you do not meet the requirements is elevated.

    -------------------------------------------
    Edwin Bills RAC
    Principal Consultant
    Bilanx Consulting LLC
    Sumter SC
    United States
    -------------------------------------------








  • 9.  RE:Risk Management for Needles (EN14971:2012)

    Posted 25-Mar-2013 10:49
    Oh, Lee, were it that simple.  In today's litigious society, especially in the US, obvious risks are targets for product liability attorneys.  Obvious risks such as hot coffee at McDonalds, have a value, witness the $3 Million awarded to the plaintiff.

    It would be wise for the medical device firm to have a serious discussion of the business risk of placing an unprotected needle on the market, when there are a number of options available to redesign the needle to provide protection and avoid injuries to users and product liability issues that result.

    As one of my fellow consultants says, "it is the product liability issues that will shut you down before the regulators".

    The EU has taken the position that all risks must be reduced until they can be reduced no more, that is their definition of "acceptable risk".  This is an expensive position for manufacturers to respond with an effective design, remembering that instructions for use are not risk reduction measures.  There are many in the US who would support this idea that, all risks must be reduced until they cannot be reduced any more.   The definition of "acceptable risk" is under assault.

    -------------------------------------------
    Edwin Bills RAC
    Principal Consultant
    Bilanx Consulting LLC
    Sumter SC
    United States
    -------------------------------------------








  • 10.  RE:Risk Management for Needles (EN14971:2012)

    Posted 06-Mar-2013 20:59
    For questions on application of the new EN ISO 14971:2012 for products sold in the EU, I recommend you contact your Notified Body for their position paper on this issue, which is a major issue for those products now. If you have a product not requiring a Notified Body, you can obtain copies of Notified Body papers on their website that explain their position and may give good guidance on how products must be developed to meet the new position.

    I need to also point out that technically EN ISO 14971:2012 contains NO new requirements, rather the three Z Informative Annexes contain information about how meeting the requirements of ISO 14971 does not meet the requirements of the three EU medical device directives.  So the additional requirements are in the directives and not the standard.  To place a product on the market, then, you must meet the requirements of EN ISO 14971:2012 (Clauses 1-9) AND also meet the requirements the the directives.  

    The EU issues also caused a new EN ISO 13485:2012 to be issued with additional Informative Annexes.

    -------------------------------------------
    Edwin Bills RAC
    Principal Consultant
    Bilanx Consulting LLC
    Sumter SC
    United States
    -------------------------------------------








  • 11.  RE:Risk Management for Needles (EN14971:2012)

    Posted 26-Mar-2013 04:14
    Thanks again for your additional comments and views. I'd like to pick up on this again.

    If we look at the discussion, we have seen that supposedly, EN ISO 14971:2012 does not contain any new requirements and it only points at the requirements of the EU directives.

    When going back to the original requirements of the directive I read the following:

    2. The solutions adopted by the manufacturer for the design and construction of the devices must conform to safety principles, taking account of the generally acknowledged state of the art.

    In selecting the most appropriate solutions, the manufacturer must apply the following principles in the following order:

    - eliminate or reduce risks as far as possible (inherently safe design and construction),

    - where appropriate take adequate protection measures including alarms if necessary, in relation to risks that cannot be eliminated,

    - inform users of the residual risks due to any shortcomings of the protection measures adopted.

    So I am asking myself where the whole discussion about "economics" comes from. I think, that the way ISO 14971:2012 is interpreting the directive is a little misleading.
    All your comments about talking to the manufacturers notified body and see how they handle the situation are true. My anticipated result is, that they will tell me and other manufacturers, that nothing changes, if they have applied the essential requirements correctly. By using a cap, we are taking into account the current state of the art.

    In sum, we can conclude that the publication of ISO 14971:2012 was meant to clarify, however, it lead to many discussions, uncertainties, work forces, meetings, communication, statements, posts like this etc.
    A good example of how intention and real life diverge from each other sometimes.

    -------------------------------------------
    Florian Tolkmitt
    sfm medical devices GmbH
    Germany
    florian.tolkmitt@sfm.de
    -------------------------------------------