MAUDE Adverse Event Report: COOPERSURGICAL, INC. KOH-EFFICIENT,RUMI,4.0CM

Model Number KC-RUMI-40

Device Problems Break (1069); Detachment of Device or Device Component (2907)

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

Event Date 03/22/2022

Event Type  malfunction  

Event Description

Complaint information provided by csi sales.End of instrument that is supposed to be welded together broke off inside patient.Follow-up initiated for additional information.Apr 21, 2022.Follow-up response was there any adverse effect as a result of reported condition? none reported.How is patient today? as best as i know fine.Was there any additional medical attention? none required.What procedure was the physician performing? did the physician perform any extra step to complete the procedure/how did physician complete the procedure/was there any fragment left in the patient? robotic hysterectomy.The cup that came off had to be retrieved in order to finish the procedure.Was there any significant delay as result of the reported condition? 30 minutes or over? roughly a 20 to 30 minute delay in the procedure time.1216677-2022-00127 koh-efficient rumi 4-0cm.

Manufacturer Narrative

Coopersurgical inc.Is currenlty investigating the condition reported.

Manufacturer Narrative

Investigation x-initiated manufacturer's investigation x-no sample returned x-review dhr *analysis and findings distribution history the complaint product was manufactured at csi on 11/17/21 under work order 312201.Manufacturing record review dhr - 312201 was reviewed and no non-conformity, related to the complaint condition, were noted.Incoming inspection review incoming inspection record review not applicable to this product.Service history record service history record not applicable to this product.Historical complaint review a review of the 2-year complaint history did not show similar reported complaint conditions.Product receipt the complaint product has not been returned to coopersurgical.Visual evaluation evaluation of the complaint product could not be completed as the complaint product has not been returned to coopersurgical.If the product should be returned at a later date, it will be evaluated, and any findings will be appended to this investigation.A picture was provided showing that the cup had become detached from the hinge.Functional evaluation evaluation of the complaint product could not be completed as the complaint product has not been returned to coopersurgical.Root cause no definitive root cause for this issue could be reliably determined at this time, since the product was not returned for investigation nor verification.With the information provided, a root cause analysis cannot be definitively performed.It is unknown if the customer used a sizer (kcp) to determine the proper size koh-efficient to use.This is listed under the dfu of the product (archkohadv-dfu).The customer was reached for additional information on the procedure and how the device may have been used, however, no information was provided.As a way of improving the manufacturing process, csi stafford has implemented 100% in process inspection of the product via bend testing and pull testing, followed by an aql qc inspection requiring the that the units also pass a bend and pull test.*correction and/or corrective action no further corrective action is necessary, as the complaint was not confirmed.*preventative action activity coopersurgical will continue to monitor this complaint condition for trends.

Event Description

: complaint information provided by csi sales."end of instrument that is supposed to be welded together broke off inside patient." follow-up initiated for additional information.Apr 21, 2022- follow-up response *was there any adverse effect as a result of reported condition? none reported *how is patient today? as best as i know fine *was there any additional medical attention? none required.*what procedure was the physician performing? *did the physician perform any extra step to complete the procedure/how did physician complete the procedure/was there any fragment left in the patient? robotic hysterectomy.The cup that came off had to be retrieved in order to finish the procedure.* was there any significant delay as result of the reported condition? 30 minutes or over ? roughly a 20 to 30 minute delay in the procedure time.(b)(4) koh-efficient rumi 4-0cm kc-rumi-40 (b)(4).

• Brand Name: KOH-EFFICIENT,RUMI,4.0CM
• Type of Device: KOH-EFFICIENT,RUMI,4.0CM
• Manufacturer (Section D): COOPERSURGICAL, INC.; 95 corporate drive; trumbull CT 06611
• Manufacturer (Section G): COOPERSURGICAL, INC,; 75 corporate drive; trumbull CT 06611
• Manufacturer Contact: michael marone ; 50 corporate drive; trumbull, CT 06611 ; 4752651665
• MDR Report Key: 14251801
• MDR Text Key: 299454016
• Report Number: 1216677-2022-00127
• Device Sequence Number: 1
• Product Code: HEW
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K954311
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: User Facility,Company Representative
• Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date: 10/23/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 04/29/2022
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Model Number: KC-RUMI-40
• Device Catalogue Number: KC-RUMI-40
• Device Lot Number: 312201
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 04/18/2022
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Unknown
• Patient Sequence Number: 1
• Patient Outcome(s): Other