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
Manufacturer
Carl Zeiss Meditec Ag (oberkochen)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.