This report is 3 of 8 for insert (cev625-1), which is linked to mfg report numbers: 2523190-2021-00212, 2523190-2021-00211, 2523190-2021-00214, 2523190-2021-00215, 2523190-2021-00216, 2523190-2021-00217, and 2523190-2021-00218.A facility reported that the forcep (with components tube, insert and handle) injured a patient when it came in contact with the small intestine.The event led to an unspecified increase of surgery time.No further information has been provided.The customer returned 12 device components, as it is unknown which device was used in this event.We are awaiting further information.
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Corrected fields: h6 (clinical code).Additional information was received on 11-october-2021: during bypass surgery, the four laparoscopy forceps injured the patient as soon as they were in contact with him.They led to some bleeding during the use on small intestine and one of them pierced the small intestine.The increase of surgery time was more than 30 minutes.No information was provided on the status of the patient now.The suspected insert (cev625-1) was returned for evaluation: the device history record (dhr) was reviewed, and no anomalies related to the reported failure were observed.Failure analysis: evaluation of the insert was unable to conclusively verify the complaint as valid.Therefore, an investigation for cause was unable to be performed.The insert was bent.It grasps improperly at the distal part.The shape of the jaws was compliant; there were no burrs or sharpened part which can explain the reported event.The reported event is not related to this device.A call was made to the customer on (b)(6) 2021 to inform that there was no traumatic part on the device and according to the operating room nurse, it was a "difficult" patient.Root cause analysis: the investigation did not highlight any defect in relation with the reported event.It may be due to the sensitivity of the patient.The insert was probably bent during the reprocessing or the storage.The grip defect was due to the repetitive uses and reprocessing of the device without servicing.Last noted repair was in 2016.
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