Mislabeling: Decontaminated Achilles tendons were distributed as 'irradiated' Achilles tendons

Record number:

119

Adverse Occurrence type:

Unsuitable MPHO released for clinical use - no harm

MPHO Type:

Tendon or Ligament

Alerting signals, symptoms, evidence of occurrence:

Noted at tissue bank

Demonstration of imputability or root cause:

surgeon considers he is implanting irradiated tissue presumably it met criteria for release and was safe

Keywords:

decontamination

References:

Vigilance and Surveillance EUSTITE Pilot Report