It was reported that during surgery, the mi z handle acet reamer cracked while reaming.The procedure was resumed, without any delay, using the same device.Patient was not harmed as consequence of this problem.
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After further assessment of the information gathered by the manufacturer, it was identified that this event should be re-evaluated for mdr reporting.It was determined that the issue does not meet the criteria to be reportable, since the crack is a fissure of device without separation of pieces, also, the part that cracked was the orange handle which is used externally to the patient.Moreover, if the device malfunction were to recur, it would not be likely to cause or contribute to a death or serious injury.The associated device was returned and evaluated.A visual inspection of the returned device reveals the orange handle is cracked.A review of complaint history revealed similar events for the listed device over the previous 12 months, but no similar events for the batch based on the historical data, this failure mode will be monitored for future complaints for any necessary corrective actions.A review of the manufacturing records did not reveal a manufacturing abnormality that could have caused or contributed to the reported incident.At this time, we do not have reason to suspect that the product failed to meet any product specifications at the time of manufacture.A review of the risk management file revealed this failure mode was previously identified.The anticipated risk level is still adequate.Assessment of historical escalated cases concluded that there are no prior actions related to this device and failure mode.This device is a reusable instrument that can be exposed to numerous surgeries.Damage from prolonged use, misuse or rough handling are likely potential factors that could contribute to the reported event.We recommend that all reusable instruments be routinely inspected for wear and damage and replaced as necessary.Based on this investigation, the need for corrective action is not indicated.Should additional information be received, the complaint will be reopened.No further investigation is warranted for this complaint; however, we will continue to monitor future complaints and investigate as necessary.We consider this investigation closed.
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