inforMED
MalfunctionHXX

ERISMA-LP MIS

Received Mar 10, 2021 · Event occurred Feb 4, 2021

Report 3009962553-2021-00001 · MDR key 11453367

Device

Generic name

Screwdriver Shaft

Manufacturer

Clariance Sas

Model number

13911009

Catalog number

13911009

Lot number

JA01N

Product problems

  • Material Fragmentation
  • Material Fragmentation

Patient

Not reported

  • Insufficient Information
  • Insufficient Information

Narrative

Description of Event or Problem

AFTER STERILIZATION HAD BEEN COMPLETED AND THE INSTRUMENTS WERE BEING PUT BACK INTO THE TRAYS IT WAS NOTICED THAT THE TIP OF THE SCREWDRIVER HAD BROKEN OFF. THE TIP WAS NOT LOCATED, AND IT IS UNSURE WHEN THE BREAKAGE OCCURRED.

Additional Manufacturer Narrative

INITIAL REPORT - ALTHOUGH THE COMPANY HAS DETERMINED THAT THE SUBJECT EVENT IN THIS MDR IS LIKELY NOT REPORTABLE, THE COMPANY HAS DECIDED TO FILE THIS MDR IN AN ABUNDANCE OF CAUTION AND TO ENSURE FULL COMPLIANCE WITH 21CFR PART 803. SUPPLEMENTAL REPORT - AS THIS ISSUE WAS NOTICED POST-SURGERY-STERILIZATION, IT IS UNSURE AS TO WHEN THE SCREWDRIVER TIP BROKE. THE COMPANY HAS DECIDED TO FILE AN MDR OUT OF AN ABUNDANCE OF CAUTION TO ENSURE FULL COMPLIANCE WITH 21CFR PART 803. THE DEVICE WAS RETURNED TO THE MANUFACTURER FOR ANALYSIS, WHICH CONCLUDED THAT THE TWO MAIN CAUSES OF SCREWDRIVER SHAFT BREAKAGE ARE DUE TO A BENDING STRESS APPLIED TO THE INSTRUMENT DURING SURGERY, AND TORSION STRESS APPLIED TO THE INSTRUMENT BY THE SURGEON SURING SURGERY.

Additional Manufacturer Narrative

ALTHOUGH THE COMPANY HAS DETERMINED THAT THE SUBJECT EVENT IN THIS MDR IS LIKELY NOT REPORTABLE, THE COMPANY HAS DECIDED TO FILE THIS MDR IN AN ABUNDANCE OF CAUTION AND TO ENSURE FULL COMPLIANCE WITH 21CFR PART 803.

Description of Event or Problem

AFTER STERILIZATION HAD BEEN COMPLETED AND THE INSTRUMENTS WERE BEING PUT BACK INTO THE TRAYS IT WAS NOTICED THAT THE TIP OF THE SCREWDRIVER HAD BROKEN OFF. THE TIP WAS NOT LOCATED, AND IT IS UNSURE WHEN THE BREAKAGE OCCURRED.

Remedial action

  • Replace