inforMED
MalfunctionGDY

ROBOTIC/LAPAROSCOPY KITTNER ROLLS MEDIUM 4" LONG 5PK 25PKS/CS

Received Jul 14, 2025 · Event occurred May 16, 2022

Report 2951379-2022-00001 · MDR key 22503008

Device

Generic name

Sterile Kittner Roll

Model number

15505/25

Lot number

1436

Product problems

  • Manufacturing, Packaging or Shipping Problem
  • Manufacturing, Packaging or Shipping Problem

Patient

25 YR · Female

  • No Clinical Signs, Symptoms or Conditions
  • No Clinical Signs, Symptoms or Conditions

Narrative

Description of Event or Problem

COUNTED 5 KITTNER ROLLS AT BEGINNING OF CASE. AT THE END OF CASE THERE WERE 6 KITTNERS. THEY MAY HAVE STUCK TOGETHER.

Additional Manufacturer Narrative

CUSTOMER REPORTED INCORRECT QUANTITY IN SKU 15505/25 LOT 1436. PACKAGE LABELED AS 5-PACK CONTAINED 6 UNITS. NO ADVERSE REACTIONS REPORTED. ROOT CAUSE DETERMINED TO BE OPERATOR OVERSIGHT DURING FINAL PACKAGING. STAFF WAS RETRAINED AND ADDITIONAL PACKAGING CHECKS IMPLEMENTED. DEVICE WAS NOT RETURNED FOR EVALUATION.

Remedial action

  • Replace