IGLESIAS WORKING ELEMENT
Received Jul 6, 2018
Report 2951238-2018-00398 · MDR key 7667956
Device
Generic name
Working Element
Manufacturer
Gyrus Acmi, IncModel number
EIWECatalog number
EIWE
Lot number
IC
Product problems
- Sparking
- Sparking
Patient
Not reported
- No Known Impact Or Consequence To Patient
- No Known Impact Or Consequence To Patient
Narrative
Additional Manufacturer Narrative
THE DEVICE WAS RETURNED TO OLYMPUS FOR EVALUATION. A VISUAL INSPECTION OF THE DEVICE FOUND CHAR MARKS INSIDE THE ELECTRODE INSERTION PORT OF THE WHITE ACTUATOR BLOCK. THE SHAFT OF THE DEVICE WAS CRITICALLY BENT AND CRACKED AT THE PROXIMAL END DAMAGING BOTH THE TELESCOPE AND ELECTRODE CHANNELS WHICH IS INDICATIVE OF USER HANDLING. IN ADDITION, THERE ARE SCRATCHES AND A COLD SOLDER JOINT BETWEEN THE SHAFT AND THE NOSE CONE. THE EXACT CAUSE OF THE REPORTED EVENT COULD NOT BE CONCLUSIVELY DETERMINED AS THE CONCOMITANT DEVICES WERE NOT RETURNED ALONG WITH THE DEVICE FOR EVALUATION. HOWEVER, BASED ON THE EVALUATION AND SIMILAR REPORTED EVENTS, THE MOST PROBABLE CAUSE OF THE REPORTED EVENT COULD BE ATTRIBUTED TO MIS-ASSEMBLY OF ELECTRODE AND ACTIVATION CORD OR FLUID/DEBRIS INSIDE THE ACTUATOR BLOCK THAT COULD HAVE CAUSED SPARK/ARC DISCHARGE WHEN THE HF CURRENT WAS ACTIVATED. THE DAMAGE AND THE COLD SOLDER JOINT ON DEVICE SUGGEST THAT THE DEVICE COULD HAVE BEEN REPAIRED BY A THIRD PARTY. THE INSTRUCTION MANUAL WARNS USERS ¿INTRODUCE A NEW PLASMAKINETIC SUPERSECT/LOOP DEVICE AND THE INSTRUMENT CABLE INTO THE STERILE FIELD. INSERT THE T-SHAPED CONNECTOR ON THE INSTRUMENT CABLE INTO THE SLOT ON THE BASE OF THE WHITE INSTRUMENT MOUNTING BLOCK. ENSURE THAT THE CONNECTOR IS FULLY SEATED WITHIN THE BLOCK.¿ IN ADDITION , THE OEM HAS ATTRIBUTED THIS TYPE OF PHENOMENON TO FLUIDS INVADING THE CONNECTION BLOCK CAUSING AN ELECTRICAL SHORT TO OCCUR DUE TO THE POOR CONNECTION OF THE ELECTRODE, WORKING ELEMENT AND CABLE.
Description of Event or Problem
OLYMPUS WAS INFORMED THAT DURING A THERAPEUTIC PROCEDURE, THE DEVICE SPARKED AT THE ELECTRODE CONNECTION POINT. THE DEVICE AND BOSTON SCIENTIFIC ELECTRODE WERE REPLACED WITH DIFFERENT DEVICES AND THE INTENDED PROCEDURE WAS COMPLETED. NO PATIENT INJURY WAS REPORTED.