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Model Number A22251C |
Device Problems
Melted (1385); Material Separation (1562)
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Patient Problem
Device Embedded In Tissue or Plaque (3165)
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Event Date 12/07/2020 |
Event Type
Injury
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Manufacturer Narrative
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The device referenced in this report has returned to olympus for evaluation.Preliminary findings are reported.The definitive cause of the customer's experience cannot be determined at this time.The investigation is ongoing.Physical evaluation of the complaint device reveals: the user's report is confirmed.The received device was not returned in the original packaging.Olympus performed a visual inspection on the received condition of the electrode and found the loop at the distal end charred, broken, and missing the roller component.The insulation covering on both sides of the distal tip appear to be melted, charred, and exposing metal wire, which is signs of use and thermal damage.The shaft portion leading up to the proximal end, appears normal.Additionally, the proximal end has normal wear.The lot number is present on the device.Olympus was unable to functionally test the electrode due to the damage.This report will be updated upon completion of the investigation or upon receipt of additional relevant information.
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Event Description
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It is reported during an ablation resection in the uterus using a hf-resection electrode (roller), the rollerball tip broke, burnt out and became damaged.The procedure was completed.The issue with the device did not impact the outcome of the procedure.X-ray performed after the procedure showed the device fragment remains inside the patient.No additional consequences to the patient have been reported.Additional details regarding the patient and event were requested from the customer with no response.
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Manufacturer Narrative
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This report is being updated to provide investigation results.New information is reported in h4, h6, and h10.The device history record (dhr) for the complaint device has been reviewed and it is confirmed that the device met all design and quality specification when it was shipped.Conclusion: : a broken electrode wire of a roller electrode is a known error pattern and can most likely be traced back to the use of excessive force, use-related wear and tear, and/or wrong handling.
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Search Alerts/Recalls
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