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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: INTEGRA LIFESCIENCES CORPORATION OH/USA MAYFIELD MODIFIED SKULL CLAMP; SKULL CLAMPS AND HEADREST SYSTEMS

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INTEGRA LIFESCIENCES CORPORATION OH/USA MAYFIELD MODIFIED SKULL CLAMP; SKULL CLAMPS AND HEADREST SYSTEMS Back to Search Results
Catalog Number A1059
Device Problem Unstable (1667)
Patient Problem Laceration(s) (1946)
Event Date 12/20/2019
Event Type  Injury  
Manufacturer Narrative
The device was not returned to the manufacturer for analysis.The plant investigation is in progress and a supplemental medwatch report will be submitted upon completion of the investigation.Linked to mfg number:3004608878-2020-00087.
 
Event Description
1 of 2 reports.It was reported that the a1059 mayfield modified skull clamp when the sales representative visited the hospital worked according to the instruction for use.One of the surgeons tested the placement by giving a little force to the mayfield after placement to check if there is flexibility due to not having contact with the skull bone.The a1047 skull pins was reported as being blunt.A patient has a wound of approximately 5 cm by 0.5 cm deep, head injury.The surgeon told the sales representative that the problem is probably due to a user mistake.Additional information received on 23jan2020 stated that the date of surgery was (b)(6) 2019, that the patient was position prone (on the belly.) the incident occurred after the placement of the clamp, by repositioning.The patient fell out of the clamp and was caught by the surgeon.The surgery continued by stitching the wound of the patient.The skull clamp is replaced, and the surgery was continued normally.The delay in surgery is 10 minutes.Request for additional information has been sent.
 
Manufacturer Narrative
Additional information:d10,g4, g7,h2,h3,h4,h6, h10.Device identifier # (b)(4).The device was returned for evaluation.The device history record reviewed with no abnormalities related to the reported failure.The device passed all required inspection points with no associated mrr¿s, variances or rework.The movement in the locking mechanism does not cause the fall of the patient¿s head.If the device is properly positioned, the slip and reported condition will not occur.The observed condition is likely caused by improper handling of the device.The definite root cause cannot be reliably determined.The reported complaint is unconfirmed.Between 05nov2019 and 30jun2020, approximately 2,200 mdrs submitted electronically by integra lifesciences via trackwise, integra's complaint handling system, were not received by cdrh due to a computer system issue.Within this time period, an error with integra's middleware, which facilitates communications between trackwise and the fda system, caused the complaint records to close and indicate we had received an acknowledgement 3 from the fda when we had not.Integra interpreted the acknowledgement as a successful submission; however, subsequent investigation revealed the acknowledgement 3 received was from our middleware and not from the fda (these acknowledgements have been retained as part of the documentation of the mdr).The malfunction was related to the relocation of the trackwise application to a new data center during the transition of integra's corporate headquarters from plainsboro, nj to princeton, nj.Previously, integra had been successfully receiving acknowledgements 1, 2, and 3 from the fda, and our records reflect these acknowledgements, including the date and time stamps.Capa pr 229048 and nc 20-011 have been opened by integra to further investigate the nonconformance and develop a corrective action plan.The middleware error has been corrected, and integra has filed mdrs since the correction and verified that the appropriate acknowledgements have been received from the fda.Integra is resubmitting all impacted mdr reports for the time period 05nov2019 through 30jun2020.Integra lifesciences contacted (b)(4) office of product evaluation and quality on july 8-9, 2020 to report these issues regarding mdr reports.
 
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Brand Name
MAYFIELD MODIFIED SKULL CLAMP
Type of Device
SKULL CLAMPS AND HEADREST SYSTEMS
Manufacturer (Section D)
INTEGRA LIFESCIENCES CORPORATION OH/USA
4900 charlemar drive
4900 charlemar drive
cincinnati OH 45227
MDR Report Key10277674
MDR Text Key204069499
Report Number3004608878-2020-00086
Device Sequence Number1
Product Code HBL
Combination Product (y/n)N
PMA/PMN Number
PRE-AMEND
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type foreign
Type of Report Initial,Followup
Report Date 01/17/2020
1 Device was Involved in the Event
1 Patient was Involved in the Event
Date FDA Received07/15/2020
Is this an Adverse Event Report? No
Is this a Product Problem Report? No
Device Operator Health Professional
Device Catalogue NumberA1059
Device Lot Number102901
Was Device Available for Evaluation? Device Returned to Manufacturer
Date Returned to Manufacturer02/20/2020
Date Manufacturer Received03/17/2020
Is This a Reprocessed and Reused Single-Use Device? No
Patient Sequence Number1
Treatment
A1047 SKULL PINS
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