Model Number 8654.204 |
Device Problem
Temperature Problem (3022)
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Patient Problem
Full thickness (Third Degree) Burn (2696)
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Event Date 10/08/2018 |
Event Type
Injury
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Manufacturer Narrative
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Rwmic submitting report on behalf of rw (b)(4) (manufacturer).As different products were used, the instructions for use of the products used in combination were reviewed.The burning was most likely caused by leakage current flowing through the patient's body in small quantities during each rf application.If the patient's body is touched by a small area during hf activation, e.G.With the fingertip, the high current density may cause combustion.In order to largely avoid the well-known phenomenon of burning by leakage current, it is recommended to keep the effect of the hf current as low as possible and to avoid skin-to-skin contact during activation.Device labeling was reviewed for patient code and device codes, see below: caution! take care not to select the wrong irrigation fluid! take care not to use high conductivity irrigation fluid for monopolar hf applications, as this would lead to increased danger of patient leakage currents, no function of the hf instrument.The user must choose the irrigation fluid as required by the application and the irrigation fluid must have a low electrical conductivity.Do not use nacl (saline) solution.Caution! danger of elevated temperatures when working without irrigation fluid! injuries to the mucous membrane due to excessive temperatures endanger the patient.Activate the electrode only while it is immersed in irrigation fluid and under continuous irrigation.(b)(4) considers this report closed.
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Event Description
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On november 07, 2018, richard wolf medical instruments corporation (rwmic) received a report from richard wolf (b)(4) involving the following devices: 815.052 lot 523/573 (mdr 9611102-2018-00015), 815.032 lot 006/086 (mdr 9611102-2018-00016), 8674.205 lot 1259038 (mdr 9611102-2018-00017), 8680.205 lot 1255367 (mdr 9611102-2018-00018), 8654.204 lot 1202777 (this mdr).It was reported that the patient suffered third degree burn on the right finger due to hf application.The device was returned to the manufacturer for evaluation.The inspection showed that the cause of the fault described by the user cannot be traced back to the working elements or hf connection cable mono.Probable root cause was determined to be use error.No defects were found in the medical devices.In conclusion, the combustion was not caused by a faulty hf device or accessory.
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Search Alerts/Recalls
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