Upon receipt of the device, the complaint was confirmed.Though investigation details from the initial reporter were not specific about an observed event, it can be inferred that the operating physician either neglected the pre-surgery device inspection or, during the case, damaged the acoustic lens of the provu transducer (7700) with the sharp distal mandrel of the accessory provu handpiece (7300).In either case, investigation has determined the cause to be use error.The operating physician was a new physician to the acessa procedure.The cavity was suctioned and cleared, and no additional surgical intervention was required.A review of the acessa provu transducer ifu (pl-01-0044 rev.Instructs users to perform a device inspection prior to use of the device, including "verify the insertion area of the transducer is free from holds, dents, scratches, cracks, deformations and color changes on the surface." users are instructed not to use the device if it does not pass this inspection.Additionally, review of the provu handpiece ifu (pl-01-0038 rev.Instructs users of caution for the sharp distal tip in the "warnings" section.Although the cavity was suctioned and cleared, and we are confident that there was no debris left, this report is being made out of an abundance of caution because, in general, if debris remains present in a patient, it could possibly necessitate medical or surgical intervention.
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On 6/20/2019, it was reported that about 75% through a case, that the acessa provu transducer with sensor (7700) was identified as having a surface defect on the silicone acoustic lens of the transducer.Prior to that point in the case, neither the operating physician nor any member of the surgical staff had observed any damage to the transducer.Upon recognition of the damaged silicone, the cavity was suctioned and cleared to ensure removal of any potential debris, with a statement of confidence from the operating physician stating that the cavity had been appropriately cleared.The case was completed successfully, there was no reported harm, injury, adverse outcome, or patient complications.
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