inforMED
OtherEIX

HU-FRIEDYNABERS PROBE WITH SATIN STEEL HANDLE

Received May 8, 2009 · Event occurred Mar 30, 2009

Report 1416605-2009-00002 · MDR key 1378577

Device

Generic name

Eix - Periodontic Probe

Model number

PQ2N7

Catalog number

PQ2N7

Lot number

R8

Product problems

  • Break
  • Detachment Of Device Component

Patient

32 YR

  • No Code Available

Narrative

Description of Event or Problem

DURING A ROUTINE PERIODONTAL EXAMINATION OF PT'S FURCATIONS, A HU-FRIEDY NABERS PROBE FRACTURED BELOW THE GINGIVAL MARGIN. THE TIP BECAME LODGED IN THE PT'S GINGIVAL TISSUE AND THE PERIODONTIST ENTERED THE SITE SURGICALLY TO REMOVE THE TIP. THE SURGICAL SITE WAS CLOSED WITH A NON-ABSORBABLE SUTURE. THE PT RETURNED TO THE PERIODONTIST'S OFFICE ON (B)(6) 2009 FOR REMOVAL OF THE SUTURE, NO COMPLICATIONS OCCURRED FROM THE SURGICAL PROCEDURE.

Additional Manufacturer Narrative

A HU-FRIEDY REPRESENTATIVE RECEIVED AN E-MAIL FROM DR. (B)(6) WITH INFO RELATED TO AN ADVERSE EVENT CAUSED BY A HU-FRIEDY NABERS PROBE. THE EVENT OCCURRED ON (B)(6) 2009 AND INVOLVED A (B)(6) MALE, NO WEIGHT INFO WAS AVAILABLE. THE INSTRUMENT WAS RETURNED ON (B)(6) 2009 FOR EVAL BY QUALITY ASSURANCE. THE INSTRUMENT, WHICH WAS MANUFACTURED IN APRIL OF 2008, BROKE AT THE FIRST 3MM MARKING. VISUAL AND DIMENSIONAL INSPECTIONS REVEALED NO MANUFACTURING DEFECTS. UPON FOLLOW-UP CONVERSATION WITH THE DOCTOR, IT WAS DETERMINED THAT THE INSTRUMENTS, WHICH ARE THIN AND FRAGILE AT THE WORKING END, MAY BE GETTING CAUGHT IN THE WIRE MESH BASKET OF THE ULTRASONIC BATH USED FOR CLEANING OF THE INSTRUMENTS. THIS COULD LEAD TO EXCESSIVE STRESS ON THE INSTRUMENT, WHICH COUPLED WITH THE FORCE APPLIED DURING THE PROCEDURE EXCEEDED THE MATERIAL'S CAPABILITY AND CAUSED THE TIP TO FRACTURE. ADDITIONAL NOTES: THE PERIODONTIST'S OFFICE WAS NOT ABLE TO PROVIDE ANY WEIGHT INFO ON THE PT. HU-FRIEDY DOES NOT TRACK OUR DEVICES, WHICH ARE MOSTLY (B)(4) DEVICES, BY SERIAL NUMBER, ONLY A LOT # WHICH IS TIED TO THE DATE OF MANUFACTURE. THE PRODUCT INVOLVED IN THE EVENT WAS (B)(6) THAT DOES NOT HAVE AN EXPIRATION DATE. THE DEVICE IS NOT IMPLANTED, THEREFORE, IMPLANT/EXPLANT DATES ARE NOT APPLICABLE.

Remedial action

  • Other