inforMED
InjuryFSO

OPMI PENTERO

Received May 29, 2024 · Event occurred Apr 1, 2024

Report 9615010-2024-00005 · MDR key 19421373

Device

Generic name

Microscope, Surgical, General & Plastic Surgery

Product problems

  • Use of Incorrect Control/Treatment Settings
  • Use of Incorrect Control/Treatment Settings

Patient

NA · Unknown

  • Full thickness (Third Degree) Burn
  • Full thickness (Third Degree) Burn

Narrative

Additional Manufacturer Narrative

H3: OTHER REASON WHY DEVICE WAS NOT EVALUATED: SERIAL NUMBER IS UNKNOWN. ACCORDING TO THE ZEISS FIELD SERVICE ENGINEER, THE CUSTOMER MIGHT LACK TRAINING AND MAY HAVE USED A HIGH INTENSITY OF XENON LIGHT. THE ROOT CAUSE OF THE REPORTED EVENT WAS A USER ERROR DUE TO HIGH INTENSITY OF XENON LIGHT USED, AND INEXPERIENCE OF THE SURGEON WHO PERFORMED THE PROCEDURE.

Description of Event or Problem

A HEALTH CARE PROFESSIONAL (HCP) REPORTED THAT A PATIENT SUSTAINED A THIRD DEGREE BURN WHICH WAS DISCOVERED DURING A FOLLOW-UP TREATMENT ONE MONTH AFTER THE INITIAL SURGERY. AN AFTER-TREATMENT OF THE BURN WITH DEBRIDEMENT AND PRIMARY CLOSURE WAS NECESSARY.