inforMED
InjuryGEI

REPROCESSED ABLATION ELECTRODE

Received Feb 23, 2017 · Event occurred Jan 13, 2017

Report 3032391-2017-00004 · MDR key 6354018

Device

Generic name

Electrosurgical Accessory

Manufacturer

Medline Renewal

Model number

AC 4045-01

Lot number

324004

Product problems

  • Material Fragmentation
  • Material Fragmentation

Patient

Not reported

  • No Known Impact Or Consequence To Patient
  • No Known Impact Or Consequence To Patient

Narrative

Additional Manufacturer Narrative

THE DEVICE IN QUESTION WAS RETURNED FOR EVALUATION, AND WE CONFIRMED THAT THE DEVICE HAD BEEN REPROCESSED. THE REPORTED ISSUE WAS CONFIRMED. A REVIEW OF THE DEVICE HISTORY RECORD CONFIRMED THAT ALL VALIDATED PARAMETERS WERE MET AND ALL REQUIRED INSPECTIONS WERE PERFORMED. THIS IS THE FIRST REPORT OF THIS TYPE OF FAILURE FOR THIS DEVICE; THEREFORE, WE WILL CONTINUE TO MONITOR TRENDS. UNFORTUNATELY, WE DO NOT HAVE ENOUGH INFORMATION AT THIS TIME TO DETERMINE THE ROOT CAUSE OF THE FAILURE. HOWEVER, IF ADDITIONAL INFORMATION SURROUNDING THE INCIDENT IS RECEIVED THEN THIS REPORT WILL BE UPDATED. THE USER REPORTED A 20-30 MINUTE DELAY DURING THE PROCEDURE BUT THERE WAS NO PATIENT CONSEQUENCE OR SUBSEQUENT INJURY. THEREFORE IN AN ABUNDANCE OF CAUTION, WE ARE FILING THIS MEDWATCH REPORT.

Description of Event or Problem

WE RECEIVED A REPORT INDICATING THAT THE TIP OF A REPROCESSED ABLATION WAND DETACHED DURING USE. THE TIP WAS DETECTED VIA X-RAY AND WAS REMOVED AT THE TIME OF THE PROCEDURE.