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MalfunctionHKY

KEELER CRYOMASTER

Received Jan 29, 2014 · Event occurred Dec 3, 2013

Report 1000391004-2014-00001 · MDR key 3727381

Device

Generic name

Cryosurgical Console

Manufacturer

Keeler Ltd.

Model number

CRYOMASTER

Catalog number

2502K8035/2502K8040

Product problems

  • Loose or Intermittent Connection
  • Device Operates Differently Than Expected
  • Naturally Worn

Patient

Not reported

  • No Consequences Or Impact To Patient

Narrative

Description of Event or Problem

DURING A CRYOSURGICAL PROCEDURE THE DEVICE ENTERED INTO A PURGING STATE UNEXPECTEDLY. DURING THE TIME THE TIP REMAINED FROZEN AND IN CONTACT WITH THE PATIENT'S EYE, AND IT WAS NOT POSSIBLE TO BREAK CONTACT WITH THE EYE UNTIL THE TIP HAD DEFROSTED FOR FEAR OF CAUSING HARM TO THE PT. IT WAS NECESSARY FOR THE PROCEDURE TO BE HALTED. THE PT WAS SEEN IN CLINIC SHORTLY AFTER THE EVENT, AND IT WAS DETERMINED THAT NO DAMAGE HAD OCCURRED AS A RESULT. THIS EVENT OCCURRED IN THE (B)(6), AND HAS BEEN REGISTERED WITH THE (B)(6).

Remedial action

  • Inspection