It was reported by the facility that during the beginning of a tonsillectomy /adenoidectomy, the surgeon stated that when he activated the bovie he witnessed a visible flame for a split second and removed the device from service.The surgical team changed the bovie pencil, tip, cautery pad and electrocautery machine before carrying on with the procedure.There was reportedly no visible injury to the patient and no impact on the procedure being performed, the procedure was able to be completed.It was reported that the device was set to 30 cut/30 coag.No additional information is available.A sample was received for evaluation.The customer returned one cautery pencil and cautery tip as a sample for our investigation.The rest of the pack was not received at this time.The end user reportedly noted a flame coming from the bovie tip.The sample was observed with dark char on the end of the cautery tip and the clear insulation appears slightly deformed, a definitive root cause was not able to be established.No additional information is available.Due to the reported incident and in an abundance of caution, this medwatch is being filed.If any further relevant information is identified or obtained, a supplemental medwatch will be submitted.
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It was reported that during the beginning of a tonsillectomy/adenoidectomy, the surgeon noticed a small flame at the tip of the bovie when he activated the device.No injury was noted to the patient, the device was immediately removed from service and replaced with a new bovie pencil.
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