It was reported, the patient underwent a therapeutic endoscopic retrograde cholangiopancreatography (ercp) for gallstone removal, and a significant stone 13x20 was detected in the common bile duct.The stone was captured in a mechanical lithotripter basket inserted into an olympus v sytem stone crusher.When breaking the stone, the wire broke at the handle, not at the preformed part of the basket.Thus, the wire and stone were stuck at the exit of the bile duct.The wire was then clamped into the emergency lithotripter, but it was still not possible to break the stone and the wire broke again at the handle, not the basket.The device was removed and the patient was taken to urgent surgery due to the device malfunction.The operation was performed that afternoon, but the patient died at dawn the next day.The physician did not see a connection between the death and the device failure, but the failure is what started the chain of events.
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