MAUDE Adverse Event Report: STRYKER INSTRUMENTS-PUERTO RICO COAXIAL FAN SPRAY TIP; LAVAGE, JET

Catalog Number 0210018100

Device Problem Disassembly (1168)

Patient Problem No Consequences Or Impact To Patient (2199)

Event Date 03/20/2014

Event Type  malfunction  

Event Description

It was reported that the coaxial fan spray tips were being used in a procedure when they fell apart.It was confirmed that the tips did not fall into the surgical site.The procedure was completed successfully, with no patient or user injuries, and no adverse consequences.

Event Description

It was reported that the coaxial fan spray tips were being used in a procedure when they fell apart.It was confirmed that the tips did not fall into the surgical site.The procedure was completed successfully, with no patient or user injuries, and no adverse consequences.

Manufacturer Narrative

A follow up report will be filed after the device is received and the quality investigation has been completed.

Manufacturer Narrative

The unit was not available to the manufacturer for evaluation as stated in the information provided since it was discarded by the customer.Therefore, the claimed condition was not confirmed.

• Brand Name: COAXIAL FAN SPRAY TIP
• Type of Device: LAVAGE, JET
• Manufacturer (Section D): STRYKER INSTRUMENTS-PUERTO RICO; las palmas industrial park; highway #3, km 130.2; arroyo 0061 5
• Manufacturer (Section G): STRYKER INSTRUMENTS-PUERTO RICO; las palmas industrial park; highway #3, km 130.2; arroyo 0061 5
• Manufacturer Contact: casey metzger ; 4100 east milham avenue; kalamazoo, MI 49001 ; 2693237700
• MDR Report Key: 3757905
• MDR Text Key: 4420377
• Report Number: 0001811755-2014-01378
• Device Sequence Number: 1
• Product Code: FQH
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: EXEMPT
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: User Facility
• Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date: 03/21/2014

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Catalogue Number: 0210018100
• Device Lot Number: 14037012
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: Yes
• Initial Date Manufacturer Received: 05/30/2014
• Initial Date FDA Received: 04/17/2014
• Supplement Dates Manufacturer Received: Not provided
• Supplement Dates FDA Received: 07/03/2014
• Was Device Evaluated by Manufacturer?: No
• Date Device Manufactured: 02/06/2014
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1