MAUDE Adverse Event Report: MEDLINE INDUSTRIES, LP; DAVINCI PACK

Catalog Number DYNJ45462B

Device Problem Appropriate Term/Code Not Available (3191)

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

Event Date 09/11/2023

Event Type  malfunction  

Manufacturer Narrative

It was reported by the customer contact that on (b)(6) 2023, "the sponge frayed while being removed through trocar".This required removal with "an instrument" and additional procedure time.It was reported " no injury, no medical intervention, surgeon thoroughly examined abdomen multiple times for remnants".A sample was requested to be returned for evaluation.It has been determined that the reported event could cause or contribute to serious injury if it were to occur.In an abundance of caution, this medwatch is being filed.If any further relevant information is identified or obtained, a supplemental medwatch will be submitted.

Event Description

"the sponge frayed while being removed through trocar".

• Type of Device: DAVINCI PACK
• Manufacturer (Section D): MEDLINE INDUSTRIES, LP; three lakes drive; northfield IL 60093
• Manufacturer Contact: kelly zampella ; three lakes drive; northfield, IL 60093
• MDR Report Key: 17876160
• MDR Text Key: 324983284
• Report Number: 1423395-2023-00055
• Device Sequence Number: 1
• Product Code: OKV
• UDI-Device Identifier: 10889942191086
• UDI-Public: 10889942191086
• Combination Product (y/n): N
• Reporter Country Code: US
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Health Professional
• Reporter Occupation: Other
• Type of Report: Initial
• Report Date: 10/05/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 10/05/2023
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Catalogue Number: DYNJ45462B
• Device Lot Number: 23FB0407
• Was Device Available for Evaluation?: No
• Date Manufacturer Received: 09/13/2023
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Unknown
• Patient Sequence Number: 1
• Patient Outcome(s): Other