KAVO DIAGNODENT 2095
Received Dec 9, 2016 · Event occurred Oct 16, 2015
Report 3003637274-2016-00074 · MDR key 6157469
Device
Product problems
- Failure To Service
- Failure To Service
Patient
2 YR
- Foreign Body In Patient
- Foreign Body In Patient
Narrative
Additional Manufacturer Narrative
THE PRODUCT WAS NOT AVAILABLE FOR THE MANUFACTURER FOR ANALYSIS, BUT A REPRESENTATIVE OF THE LOCAL DEALER VISITED THE CUSTOMER TO CHECK THE ROOT CAUSE. IT TURNED OUT QUICKLY THAT THE SNAP-ON MOUNTING OF THE LIGHT PROBE WAS WORN OUT. IT WAS VERIFIED BY COMPARING THE RETENTION FORCE BETWEEN A NEW LIGHT PROBE (WHICH WAS GOOD) AND THE USED ONE. IT TURNED OUT THAT THE CUSTOMER DID NOT FOLLOW THE STERILIZATION PROCESS AS DESCRIBED IN THE INSTRUCTION FOR USE AND ALSO NOT THE INSTRUCTION HOW TO PREPARE THE PRODUCT FOR USE. HENCE CUSTOMER GOT NOT AWARE THAT THE LIGHT PROBE WAS NOT CORRECTLY IN PLACE. TO AVOID SUCH INCIDENTS THE INSTRUCTION FOR USE CONTAINS ALREADY THE NECESSARY INSTRUCTIONS HOW TO MAINTAIN AND USE THE PRODUCT: OPERATION / HANDLING: SELECT LIGHT PROBE A OR B AND PLACE ON HANDPIECE. MAKE SURE THE PROBE IS PROPERLY SEATED. SETUP METHODS ACCORDING TO DIN EN ISO 17664. RESTRICTION ON REUSE: THE PROBES CAN BE STERILISED MORE THAN 500 TIMES WHEN HANDLED PROPERLY. THE PROBES ARE SUBJECT TO WEAR. STERILISATION: ONLY THE GRIP SLEEVES AND PROBES CAN BE STERILISED UP TO 138°C. THE PROBES CAN BE STERILISED IN THE PROBE HOLDER IN THE STERIBOX.. INSERT THE PROBES IN THE PROBE HOLDER IN THE STERIBOX IN THE RIGHT PROBE STORAGE SPACE. PRODUCT NOT SUPPLIED BY OWNER.
Description of Event or Problem
IT WAS REPORTED THAT DURING A DENTAL MEDICAL EXAMINATION THE LIGHT PROBE DETACHED FROM THE GRIP SLEEVE, FELL INTO PATIENTS MOUTH AND WAS SWALLOWED BY PATIENT ((B)(6) INFANT). TWO DAYS LATER THE PROBE WAS DEFECATED ON THE NATURAL WAY WITHOUT CAUSING ANY TROUBLE. NO MEDICAL CARE WAS NECESSARY. THE INCIDENT OCCURED MORE THAN ONE YEAR AGO AND FURTHER DETAILS ARE NOT AVAILABLE. HENCE THE 'DATE OF EVENT' IS BEST ESTIMATE.