inforMED
MalfunctionBRT

HOLDER LEG

Received May 16, 2017 · Event occurred Apr 3, 2017

Report 1219602-2017-00495 · MDR key 6571146

Device

Generic name

Restraint, Patient, Conductive

Catalog number

012310

Lot number

EPO

Product problems

  • Device Operates Differently Than Expected

Patient

Not reported

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

Narrative

Additional Manufacturer Narrative

ONE LEG HOLDER WAS RETURNED FOR EVALUATION. VISUAL ASSESSMENT OF THE DEVICE SHOWS IT IS WELL WORN. THERE IS DAMAGE TO THE PADS AND THEIR ASSEMBLIES. THE POSITIONING LOCKS THREADS ARE STRIPPED. THE PLATING IS COMING OFF OF THE LATERAL PAD LOCK ASSEMBLY. A MACHINE SCREW HAS BEEN PLACED IN THE LATERAL PAD LOCK ASSEMBLY. THE DEVICE IS IN NEED OF COMPLETE REFURBISHMENT AND LIKELY DID AT THE TIME OF THIS INCIDENT. WE RECOMMEND THAT ALL RE-USABLE INSTRUMENTS BE ROUTINELY INSPECTED FOR WEAR/DAMAGE AND REPLACED OR REPAIRED AS NECESSARY. NO ROOT CAUSE RELATED TO THE MANUFACTURE OF THE DEVICE CAN BE ESTABLISHED. NO FURTHER INVESTIGATION IS WARRANTED AT THIS TIME.

Description of Event or Problem

IT WAS REPORTED THAT DURING THE PROCEDURE THE PIN WILL NOT KEEP THE LEG LOCKED. A BACK UP DEVICE OF THE SAME KIND WAS AVAILABLE TO CONTINUE THE PROCEDURE. NO PATIENT HARM WAS REPORTED. THE LEG WAS ABLE TO SHIFT/ROTATE BUT IT IS UNKNOWN IF TRACTION WAS LOST.