H10: additional information in d10.Results of investigation: the device, used in treatment, was returned for evaluation.A visual inspection of the returned device confirms a piece of the corner of the device broke off.Both pieces were returned for evaluation.The device shows extreme signs of wear/usage.The device was manufactured in 2016.A medical investigation was conducted and this case reports the corner of the trial insert cracked while inside the patient.Per complaint details, the procedure was completed using a backup device, with further complications.A photo of the device confirms the cracked corner.Therefore, since no patient harm is alleged, no further assessment is warranted at this time.A complaint history review found related failures; this failure mode will be monitored for future complaints for any necessary corrective actions.A review of the manufacturing records did not reveal a manufacturing abnormality that could have caused or contributed to the reported incident.A review of risk management files found that the reported failure was documented appropriately.The device is a reusable instrument that can be exposed to numerous surgeries and cleaning cycles.As plastics are vulnerable and crack may have initiated during use and possible causes could be due to the heating and cooling associated with autoclaving or prolonged use.We recommend that all reusable instruments be routinely inspected for wear and damage and replaced as necessary.At this time, we have no reason to suspect that the product failed to meet any product specifications at the time of manufacture.
|