inforMED
MalfunctionIWY

TYPE-S HEAD EXTENSION

Received Apr 20, 2007 · Event occurred Mar 26, 2007

Report 1932738-2007-00001 · MDR key 950580

Device

Generic name

Carbon Fiber Couch Insert

Model number

20-CFHN-SUB2-V

Catalog number

20-CFHN-SUB2-V

Lot number

2901

Product problems

  • Break

Patient

YR

  • Fall
  • Pain
  • Discomfort
  • Therapy/non-surgical treatment, additional

Narrative

Description of Event or Problem

CIVCO WAS NOTIFIED THAT A TYPE-S HEAD EXTENSION JOINT BROKE NEAR THE LOCKING MECHANISM AND ALLOWED THE PATIENT TO FALL. THE PATIENT WAS LYING FLAT ON THEIR BACK AS THEY ADJUSTED THEMSLEF OF THE TYPE-S HEAD EXTENSION. THE TYPE-S HEAD EXTENSION BROKE AND THE PATIENT FELL ABOUT 2-3 FEET. THE PATIENT WAS EVALUATED BY X-RAY AND NO INJURY WAS IDENTIFIED.

Additional Manufacturer Narrative

CLINICIAN/HOSPITAL GLUED JOINT TOGETHER PRIOR TO RETURNING FOR EVALUATION WHICH MADE EVALUATION OF THE ORIGINAL JOINT ADHESIVE IMPOSSIBLE. PATIENT REPOSITIONED SELF PUTTING EXCESSIVE PRESSURE ON WORN DEVICE. INSTRUCTIONS FOR USE DESCRIBES AND DIAGRAMS CORRECT REPOSITIONING PROCESS OF PATIENT/CLINICIAN. INSTRUCTIONS FOR USE INDICATE TO INSPECT FOR DAMAGE/WEAR PRIOR TO USE AND NOT TO USE A DAMAGED DEVICE.

Remedial action

  • Replace