A physician reported that on (b)(6) 2020, the perforator was used to make a third hole for a craniotomy.The perforator failed to disengage and injury to the dura mater was reported and a brain contusion was reported.Hemostasis was performed and a surgical delay of less then 30 minutes was noted.As the hole which had occur the disengagement failure was the last hole, the procedure was completed without another device.
|
The perforator was returned for evaluation.Device history record (dhr): there is no indication that the production process may have contributed to this complaint.All test results passed procedural specifications.Failure analysis - the perforator unit was inspected using the unaided eye.The returned unit was soiled from surgery, no other anomalies were observed.Instructions for use testing was performed with no observed anomalies.Testing included: applying adequate pressure on the perforator point, ensuring engagement occurs as the hudson end is rotated.Placing thumb pressure on the perforator point to ensure a smooth, positive spring action when engagement occurs.Ensuring the hudson end rotates smoothly within the perforator body when the unit is in the disengaged position.Functional testing was performed using the same protocol it underwent at finished goods testing prior to release.The unit was found to perform as intended and fulfilled the acceptance criteria.In conclusion, the returned unit was found to work as intended, and met all acceptance criteria.The complaint could not be verified through failure analysis.The root cause is undetermined and was unable to be confirmed in the complaint evaluation.
|