MAUDE Adverse Event Report: ZIMMER ZIMMER SELF-TAPPING BONE SCREW

Catalog Number 00625006530

Device Problem Break (1069)

Patient Problem Device Embedded In Tissue or Plaque (3165)

Event Date 04/29/2015

Event Type  malfunction  

Event Description

It is reported that during surgery, while tightening the screw into cup, the head of the screw broke and it was left in the patient.

Manufacturer Narrative

This report will be amended when our investigation is complete.

• Brand Name: ZIMMER SELF-TAPPING BONE SCREW
• Manufacturer (Section D): ZIMMER; route 1, km. 123.4, bldg. 1; turpeaux industrial park; mercedita 00715
• Manufacturer Contact: kevin escapule ; p.o box 708; warsaw, IN 46581-0708 ; 8006136131
• MDR Report Key: 4818397
• MDR Text Key: 16546816
• Report Number: 2648920-2015-00188
• Device Sequence Number: 1
• Product Code: MRA
• 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,Distributor
• Reporter Occupation: Other
• Type of Report: Initial
• Report Date: 04/29/2015

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: 00625006530
• Device Lot Number: 62837003
• Was Device Available for Evaluation?: Yes
• Date Returned to Manufacturer: 05/07/2015
• Is the Reporter a Health Professional?: No
• Initial Date Manufacturer Received: 04/29/2015
• Initial Date FDA Received: 06/02/2015
• Was Device Evaluated by Manufacturer?: No
• Date Device Manufactured: 10/01/2014
• 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