MAUDE Adverse Event Report: TELEFLEX MEDICAL HOL ML 5MM ENDO APPLIER; APPLIER, SURGICAL, CLIP

Model Number IPN915189

Device Problem Activation, Positioning or Separation Problem (2906)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Date 06/18/2021

Event Type  malfunction  

Manufacturer Narrative

(b)(4).The device has not been returned for investigation.Teleflex will continue to monitor and trend related events.

Event Description

The pivot pin got detached during a surgery.Therefore, the applier was replaced with a new one.Nothing fell/remained in the patient.The applier was purchased by the hospital in (b)(6) 2021.

Manufacturer Narrative

(b)(4).The dhr for the returned instrument was reviewed and found completely without any nonconformance's or irregularities.It was also found that this order was made from the correct materials and components.This instrument was produced on shop order 50289610 at the tecomet, inc.Kenosha wi facility as part of a 50-piece lot in march of 2020.Evaluation of the returned instrument shows that the jaws are loose and misaligned , and the jaw pivot pin is pulled thru one side of the bent/damaged outer tube assembly and the drive rod (n00185) is also bent/damaged in the area that it engages the jaws.We are able to validate this complaint.After the initial evaluation this instrument was dis-assembled in order to evaluate its internal components and it was found that the inner drive rod (n00185) fingers are both damaged where they engage the jaws.Mishandling of this device at the end user's facility is suspected.All 50 instruments from this lot were 100% visually inspected and function tested prior to shipment to the customer as this is a standardized procedure at this facility for this product line.Due to these findings , no further actions will be taken in response to this complaint and this record will be deemed closed.

Event Description

The pivot pin got detached during a surgery.Therefore, the applier was replaced with a new one.Nothing fell/remained in the patient.The applier was purchased by the hospital in (b)(6) 2021.

• Brand Name: HOL ML 5MM ENDO APPLIER
• Type of Device: APPLIER, SURGICAL, CLIP
• Manufacturer (Section D): TELEFLEX MEDICAL; morrisville NC
• MDR Report Key: 12085156
• MDR Text Key: 258979350
• Report Number: 3011137372-2021-00163
• Device Sequence Number: 1
• Product Code: GDO
• UDI-Device Identifier: 24026704696813
• UDI-Public: 24026704696813
• Combination Product (y/n): N
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: foreign,health professional
• Type of Report: Initial,Followup
• Report Date: 06/18/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 06/29/2021
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: IPN915189
• Device Catalogue Number: 544965
• Device Lot Number: 06F1989610
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 07/09/2021
• Date Manufacturer Received: 08/04/2021
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1