MAUDE Adverse Event Report: PROMED INSTRUMENTS GMBH DORO (R) ALUMINUM SKULL CLAMP; HEADHOLDER

Model Number 3003-00

Device Problem Difficult or Delayed Positioning (1157)

Patient Problems Laceration(s) (1946); Injury (2348)

Event Date 04/15/2013

Event Type  malfunction  

Event Description

The customer reported on (b)(6) 2013 that there was a pt slippage in "early (b)(6) 2013" with laceration but no serious pt injury occurred.Surgery was completed."while in prone pt's head slid towards the floor while in the head clamp, pins caused a scalp laceration.The device was received at pmi for inspection on 04/19/2013.

Manufacturer Narrative

Root cause: failure reported by customer but product is within spec.Device evaluated and alleged failure could not be duplicated.Suspected root cause: wrong pinning technique.Root cause: failure reported by customer but product is within spec.Device evaluated and alleged failure could not be duplicated.Suspected root cause: wrong pinning technique.Corrective action: instructed customer to properly position the pt's head.Ensure that the 2 skull pins in the rocker arm are equidistant from the centerline of the head and that all 3 pins are penetrating the skull equally.The angle of the pins should be as close to 90 degrees possible to the pt's skull.Test that the skull clamp ext.Arm is fully engaged in the clamp base.Lock the index knob so that the arrow and "lock" are aligned.Device was returned and can be used as intended.Returned product and another copy of the instruction manual to customer.

• Brand Name: DORO (R) ALUMINUM SKULL CLAMP
• Type of Device: HEADHOLDER
• Manufacturer (Section D): PROMED INSTRUMENTS GMBH; boetzinger strasse 38; freiburg 7911 1; GM 79111
• Manufacturer Contact: lutz babilon ; boetzinger strasse 38; freiburg 79111 ; GM 79111 ; 6138422242
• MDR Report Key: 4249920
• MDR Text Key: 4986503
• Report Number: 3003923584-2014-00011
• Device Sequence Number: 1
• Product Code: HBL
• Combination Product (y/n): N
• Reporter Country Code: CA
• PMA/PMN Number: K001808
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Foreign,Distributor
• Reporter Occupation: Nurse
• Type of Report: Initial
• Report Date: 04/22/2013

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 11/06/2014
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: 3003-00
• Was Device Available for Evaluation?: Yes
• Date Returned to Manufacturer: 04/19/2013
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 04/19/2003
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 06/01/2010
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Unknown
• Patient Sequence Number: 1