Model Number 261221 |
Device Problem
Fail-Safe Did Not Operate (4046)
|
Patient Problem
Hemorrhage/Bleeding (1888)
|
Event Date 12/27/2022 |
Event Type
Injury
|
Manufacturer Narrative
|
An investigation has been initiated based on the reported information.Upon completion of the investigation, a follow-up report will be submitted.
|
|
Event Description
|
A physician reported disengagement failure of a disposable perforator (id 261221) causing bleeding during making the first burr hole at the tent.Hemostasis was performed.The drill used with the perforator was a midas (medtronic).Based on information provided, it is unknown if the perforator clicked in place on the drill.It is also unknown if the recommended spring tests were performed between each burr hole.The event did not led to surgical delay.No further information was provided by hospital.
|
|
Event Description
|
N/a.
|
|
Manufacturer Narrative
|
Additional information received: "the possibility of dural damage or vascular damage cannot be denied as the cause of the large amount of bleeding.".
|
|
Event Description
|
N/a.
|
|
Manufacturer Narrative
|
Perforator (id 261221) has been returned for evaluation: device history record (dhr)- there is no indication that the production process may have contributed to this complaint.All test results passed procedural specifications.Failure analysis - visual inspection utilizing unaided eye performed: unit had a worn label and the lot # could not be determined via visual inspection.Tooling was observed at the end of the outer drill.Spring test attempted: unit passed the spring test and was determined to function as designed.Functional test performed: unit successfully drilled 5 holes with no issues and was found to function as intended.Unit was found to meet all acceptance criteria.Therefore, the complaint condition could not be confirmed.Root cause- the root cause is undetermined and was unable to be confirmed in the complaint evaluation.Possible root cause is "user misuse" as the perforator functioned as designed and passed all acceptance criteria during the failure analysis performed.
|
|
Search Alerts/Recalls
|