1.Description of incident.During a colonoscopy, there was a polyp found, we opened a cold snare.While trying to remove the polyp with the snare, the tip of the snare broke off.It was retrieved from the patient and sequestered.The staff in the room opened a different type of snare and was able to remove the polyp.There was no harm to the patient.Complaint specification: cs2-21023231, complaint batch number: m230604307, check the production record of this batch, a total of (b)(4) pcs were produced in this batch, and the products put in storage and sold are all qualified products.2.Cause analysis.According to customer complaint feedback information, combined with historical customer complaint and product structure, we investigate the intended use, raw materials, production process, instructions for use and storage, and the specific investigation information is as follows.2.1 intended use.The cold snare is indicated for use endoscopically for the removal of diminutive polyps, sessile polyps, pedunculated polyps and tissue from within the gastrointestinal tract.Analysis: the description of intended use is clear and clear, and there will be no ambiguity in "removing small polyps, nonstultiform polyps, and stultiform polyps and tissues from gastrointestinal tract".In addition, from (b)(6) 2023, we sold about a total of (b)(6) cold snare devices.According to statistics, this type of complaint has occurred for the 6th time, with a probability of (b)(4).The probability of occurrence is very low, so we can be sure that the intended use of cold snare can meet clinical requirements.2.2 raw material.Cold snare consists of loop, outer tube, plunger rod, sliding block, etc.Raw materials shall be put into storage after their materials, appearance and dimension are qualified.Iqc will randomly draw the raw materials at the time of incoming materials.After inquiry, the batch number of original materials of loop corresponding to this batch is 20230428j01-i011 and 20230517j18-i004.This batches of tensile force test is ok.2.3 production process.According to the batch number provided by the customer, we checked dhr and found that the batch number of this batch of finished products corresponded to 2 batches of snare assembly.The production process: the first and last inspection of riveting tension, ipqc inspection, finished inspection and delivery inspection were all qualified.Therefore, the failure of riveting tooling caused by unqualified tension caused by snare falling off was excluded.2.4 instructions for use.2.4.1.Retract the handle of the snare and confirm that the snare loop is fully retracted into the catheter prior to inserting the catheter into the endoscope.2.4.2.Slowly advance the catheter through the endoscope channel until the tip appears in the endoscopic view and the lesion is clearly identified and targeted.2.4.3.Operate the hande to extend the snare loop and gently snare the target tissue; note: the snare loop can be rotated if desired by holding the outer sheath assembly and rotating the handle.2.4.4.Confirm appropriate tissue is captured and proceed to resect by gently pulling the slider.2.4.5.Repeat steps 3&4.Retract the snare prior to removing the instrument from the endoscope.Analysis: the ifu clarifies the method of use: " operate the hande to extend the snare loop and gently snare the target tissue ".The description is clear and clear, and there will be no ambiguity, so we can confirm this complaint has nothing to do with the method of use described in the ifu.2.5 storage we have specific requirements for the storage of cold snare products: the product should be stored in a cool, dry, clean, well-ventilated, non-corrosive gas environment.Do not expose the package to organic solvent, ionizing radiation or ultraviolet radiation.Analysis: the cold snare was validated for the shelf life in detail during the design and development stage, which confirmed that the cold snare is safe and effective during the shelf life.More detailed storage conditions are also described in the instructions.Therefore, we can determine that this cold snare complaint is not related to storage.Summary: after investigating the intended use, raw materials, production process, applicable instructions and storage of the cold snare, all met the requirements of the standards, no defective pictures and samples were received, no more relevant information was available, and no further analysis was possible.Therefore, no root cause of the cold snare breakage was found, and we will pay continuous attention to it.
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