inforMED
InjuryFSZ

METRX SYSTEM

Received May 27, 2011 · Event occurred Apr 13, 2011

Report 1030489-2011-00628 · MDR key 2105058

Device

Generic name

Light, Surgical, Carrier

Model number

NA

Catalog number

9560702

Lot number

0135693W

Product problems

  • Overheating of Device

Patient

00042 YR

  • Superficial (First Degree) Burn

Narrative

Description of Event or Problem

IT WAS REPORTED THAT THE PATIENT UNDERWENT A MINI-INVASIVE SPINAL PROCEDURE. THE PATIENT HAD A RECTANGULAR BURN ON HIS BACK INTRAOPE RATIVELY WHERE THE LIGHT BOX CABLE MEETS THE LIGHT SOURCE. IT WAS DISCOVERED IMMEDIATELY AFTER SURGERY. THE BURN WAS ABOUT AN INCH AND A HALF AROUND. THE HOSPITAL CONFIRMS THAT THE LIGHT SOURCE WAS USED WITH A LIGHT BOX SETTING ON AROUND 300 WATTS. THE HOSPITAL STATED THAT THE STAFF WAS NOT AWARE OF THE WARNING LABEL ON THE PRODUCT PACKAGING THAT REFERENCES USING A 100 WATT LIGHT SOURCE. REPORTEDLY, THE PATIENT WAS TREATED AT THE OFFICE AND GIVEN A CREAM. NO OTHER PATIENT COMPLICATIONS WERE REPORTED.

Additional Manufacturer Narrative

DEVICE HISTORY RECORDS WERE REVIEWED. NO DOCUMENTATION WAS FOUND THAT WOULD INDICATE A NON-CONFORMANCE TO SPECIFICATIONS.

Additional Manufacturer Narrative

(B)(4). DEVICE WAS NOT RETURNED TO THE MANUFACTURER FOR EVALUATION. WE ARE UNABLE TO DETERMINE THE CAUSE OF THE EVENT. A REVIEW OF DEVICE HISTORY RECORDS IS NOT POSSIBLE AT THIS TIME WITHOUT ADDITIONAL DEVICE INFORMATION.