This supplemental report is being supplemented to provide additional information based on the original equipment manufacturers (oem) evaluation.The oem¿s investigation is consistent with the customer¿s report, and the working element was manufactured in march 2012.Visual inspection of the working element showed considerable signs of wear and tear like corrosion, dents, and scratches and worn inscription.The working element¿s electrode guiding tube on the distal end is heavily damaged.The gold-plated cone shows developed corrosion.Considerable signs of hf spark-over and corrosion are evident.The connection area between working element and hf cable shows considerable traces of arcing.The working element passed the functionality check with following results: locking mechanism functions normally, the electrode clicks into position audibly.The locking mechanism of the electrode has no damages.The oem performed a leakage test with instrument combination of working element, telescope and the electrode passed without showing any abnormalities.The working element passed the electrical strength test.It was determined that the previously reported leakage of ¿fluid came out of the seal¿ was observed when the moisture leaked from the teflon body.However, the investigations verified the electrical resistance to be = 5ohm conforming to the specification.A visual inspection of customer¿s hf-resection oval button electrode model: wa22566s was performed and found the insulation tube of the hf-resection electrode with more or less severe mechanical damage, especially the area affected by hf arcing.It was noted be considerably worn inscription of the hf-resection electrode and observed stress marks inside the telescope guiding tube indicate repeatedly use of the single use electrode.The distal end of hf-resection electrode was noted to be severely deformed.Thereby the insulation tube of the electrode got damaged to the extent of failed electrical strength.There was also evidence that during use, four short circuits occurred at least between the electrode and the working element.Based on the investigation findings, the root cause for charred stains and developed corrosion on the working element is traced back to the incorrect and/or insufficient reprocessing/drying as well as improper assembly of the hf-resection electrode leading to spark discharge and instrument damage.The risk associated with this damage was assessed as acceptable, when considering the hints and caution notes included in the instructions for use.The instruction manual warns users ¿make sure that the product has been properly reprocessed, inspected, and tested before use.Make sure that it has no corrosion, no dents, and no scratches.When attaching the electrode to the working element, make sure that the electrode clicks into position audibly, and check the locking mechanism and position of the electrode.If the electrode is not attached securely to the working element, spark discharge may occur and the instrument may be damaged.¿ a review of the dhr was performed and noted no anomalies during the manufacturing of this device and lot number.
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This supplemental report is being submitted to correct the lot number of the device and provide additional information received from the oem.The oem evaluation attributed the root cause of the reported event to improper handling / off-label use, as the hf-resection electrode has been improperly assembled leading to spark discharge and instrument damage.Furthermore, the damage to the laser marking and grinding marks on the optical guide tube of the electrode indicate a multiple use of the sterile packaged single use electrode.In addition, distal end of the oval button is strongly deformed, which means probably the electrode was used in the defective condition.
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