DRILL BIT SMALL QUICK COUPLING (SQC) 2.0MM 100/21.5MM
Received Sep 23, 2024 · Event occurred Aug 13, 2024
Report 2249529-2024-00002 · MDR key 20287002
Device
Product problems
- Break
- Break
Patient
70 YR · Male
- Discomfort
- Discomfort
Narrative
Description of Event or Problem
IT WAS REPORTED THAT DRILL BIT BROKE DURING ORTHOPEDIC SURGERY AND THE BROKEN DRILL BIT WAS RETRIEVED FROM THE PATIENT'S BODY. THIS IS A RECURRING EVENT PER HOSPITAL INVOLING SAME DRILL BIT WITH SAME LOT#.
Additional Manufacturer Narrative
THIS REPORT DETAILS THE INVESTIGATION ( (B)(4) ) INTO THE BREAKAGE OF THREE DRILL BITS USED IN ORTHOPEDIC SURGERIES, AS REPORTED IN THREE SEPARATE MEDICAL DEVICE REPORTS (MDRS). PART NUMBER: GS 86.8220, LOT NUMBER: 5232413, USER FACILITY MDR REFERENCES: MW5158653, MW5158654, MW5158655, REFERENCE TO ANOTHER COMPLAINT: (B)(4), [MDR# 2249529-2024-00001]. ALL THREE MDRS REFERENCE THE SAME PATIENT DETAILS, INDICATING A HIGH LIKELIHOOD OF DUPLICATE REPORTING BY THE USER FACILITY. EMAIL COMMUNICATIONS CONFIRM THAT ONLY ONE REPORT WAS INTENDED FOR SUBMISSION THE SPECIFIC ORTHOPEDIC SURGERIES PERFORMED WERE NOT DETAILED IN THE REPORTS, LIMITING OUR UNDERSTANDING OF THE CONTEXT. DESPITE MULTIPLE REQUESTS, NO BROKEN DRILL BITS WERE RETURNED FOR EVALUATION. FINDINGS INDICATE NO DESIGN OR MANUFACTURING DEFECTS. PRODUCTION AND FINAL QUALITY ASSURANCE (QA) REVIEWS (DHR) CONFIRM COMPLIANCE WITH SPECIFICATIONS. IN-HOUSE TESTING WAS CONDUCTED ON DRILL BITS FROM A DIFFERENT LOT REVEALED NO BREAKAGE DURING TESTING. 50 DRILL BITS FROM LOT # 5232413 WERE PRODUCED AND NO ADDITIONAL COMPLAINTS FROM OTHER CUSTOMERS USING THIS LOT, INDICATING THAT THE REPORTED ISSUES MAY BE ISOLATED. IT IS LIKELY THAT THE SAME SURGEON PERFORMED THE REPORTED SURGERIES. THIS RAISES THE POSSIBILITY THAT SURGICAL TECHNIQUE MAY HAVE INFLUENCED THE INCIDENTS. THE INVESTIGATION REVEALS NO INHERENT ISSUES WITH THE DRILL BITS. THE BREAKAGES APPEAR TO BE ISOLATED CASES AS SURGICAL TECHNIQUE CANNOT BE RULED OUT AS A CAUSE. A FOLLOW-UP REPORT WILL BE FILED IF ADDITIONAL INFORMATION BECOMES AVAILABLE.