Model Number A2114 |
Device Problems
Device Slipped (1584); Mechanics Altered (2984)
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Patient Problem
Laceration(s) (1946)
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Event Date 10/19/2022 |
Event Type
Injury
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Manufacturer Narrative
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An investigation has been initiated based on the reported information.Upon completion of the investigation, a follow-up report will be submitted.
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Event Description
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A facility reported that during a craniotomy procedure, mayfield infinity xr2 skull clamp (a2114) slipped.The mayfield was in place on patient with the rotation locked in place and pressure gauge set at 80 pounds on the pin, but while positioning the patient prone, the mayfield swung loose and the ratcheting system also came apart causing scalp laceration to the patient.The laceration was closed with staples and patient was re-pinned and repositioned with a different mayfield.Patient outcome reported as doing fine but has a big laceration on her scalp.
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Manufacturer Narrative
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Updated fields: g3, g6, h2, h6 (health impact code), h10.Additional information received on 09nov2022: was there surgical delay due to product problem? yes there was a delay of 30 min.We had to re-position and take care of the patient's laceration.
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Event Description
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N/a.
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Manufacturer Narrative
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The mayfield infinity xr2 skull clamp (a2114) was returned for evaluation: device history record (dhr): the dhr was reviewed and shows no abnormalities related to the reported failure.Failure analysis: evaluation of the returned skull clamp showed that it was in good working order and passes quality inspection.Also, no maintenance required at this time.Root cause: probable root cause is improper or suboptimal positioning of the skull clamp on the patient.If additional relevant information becomes available in the future, this complaint will be reopened, and the respective evaluation performed.Trends will be monitored for this and similar issues.At present, we consider this complaint to be closed.
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Event Description
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N/a.
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Search Alerts/Recalls
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