|
Model Number M00522612 |
Device Problems
Break (1069); Activation, Positioning or Separation Problem (2906); Difficult to Open or Close (2921)
|
Patient Problem
No Consequences Or Impact To Patient (2199)
|
Event Date 11/02/2020 |
Event Type
malfunction
|
Manufacturer Narrative
|
Device captures the reportable event of clip failed to release from the catheter.Although the suspect device has been received, the evaluation has not been completed.Therefore, the cause of the reported malfunction has not been determined.Upon completion of the failure analysis of the complaint device, if there is any further relevant information from that review, a supplemental mdr will be filed.
|
|
Event Description
|
It was reported to boston scientific corporation that a resolution clip device was used during a colonoscopy procedure performed on (b)(6) 2020.According to the complainant, during the procedure, the clip was tried to open, but it did not open correctly.The clip finally opened and it was able to grasp and lock onto tissue; however, the clip did not separate from the catheter to deploy.Reportedly, the pop stage of deployment was not heard and the control wire in the handle was broken so no resistance was felt.The procedure was completed with another resolution clip device.There were no patient complications reported as a result of this event.
|
|
Event Description
|
It was reported to boston scientific corporation that a resolution clip device was used during a colonoscopy procedure performed on (b)(6) 2020.According to the complainant, during the procedure, the clip was tried to open, but it did not open correctly.The clip finally opened and it was able to grasp and lock onto tissue; however, the clip did not separate from the catheter to deploy.Reportedly, the pop stage of deployment was not heard and the control wire in the handle was broken so no resistance was felt.The procedure was completed with another resolution clip device.There were no patient complications reported as a result of this event.
|
|
Manufacturer Narrative
|
Block h6: device code 2906 captures the reportable event of clip failed to release from the catheter.Block h10: investigation results: the returned resolution clip device was analyzed, and a visual evaluation noted that the clip assembly was not returned with the device.The device was returned without the over-sheath.It was also observed that the device was returned completely disassembled with the catheter was cut from the handle.The control wire was returned outside of the catheter, was kinked and the spool was separated from the handle.The catheter was kinked and unraveled at the most distal section.Microscope examination was performed; the bushing had hits on its hooks, and one of the bushing tabs was rounded, indicating that the observed failures could be evidence of difficulty experienced when attempting to release the clip from the catheter.Dimensional examination was performed to further analyze the deployment issue, and the bushing outside diameter was confirmed to be within specification.A dimensional analysis was also performed between the hooks of the bushing, and both sides a and side b were found to be ouf of specification.No other issues with the device were noted.The reported event was not confirmed.This failure is likely due to problems traced to manufacturing process.Therefore, the most probable root cause is manufacturing deficiency.An investigation is in place to address this issue.A review of the device history record (dhr) was performed and confirmed that this device met all material, assembly and performance specifications.A review of the instructions for use (ifu) and product labeling was completed and did not reveal any evidence of device misuse or that the device was used in a manner inconsistent with the labeled indications.
|
|
Search Alerts/Recalls
|
|
|