MAUDE Adverse Event Report: RICHARD WOLF GMBH ERAGON BIPOLAR; GRASP. FORCEPS INSERT Ø 5.5MM

Model Number	83930031
Medical Device Problem Code	Detachment of Device or Device Component (2907)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	06/02/2020
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The present inner part eragon bipolar was checked in the responsible department.One of the two industry parts has broken off at the bottom of the interlocking.The 83930031 inner part eragon bipolar from batch 1376078 was booked into stock on (b)(6)2018 and (b)(6) 2018.With the corresponding production order 1376078 a total of 23 pieces of the inner part eragon bipolar were produced.On (b)(6) 2018, 3 inner part eragon bipolar were delivered to the customer from batch 1376078.The inner part eragon bipolar is in the sales program of richard wolf since (b)(6) 2008.The database of complaints was examined in the period (b)(6) 2017 to (b)(6) 2020.During this period, 967 pieces of the 83930031 inner part eragon bipolar were sold.During the period under review there was a comparable complaint of the inner part eragon bipolar.The intended use of the inner part eragon bipolar under endoscopic view with bipolar hf current is as follows: gripping, manipulation, cutting.Dissection of soft tissue areas/organs.Coagulation, hemostasis, tissue separation.Removal of tissue samples.In the ga-b 241 / de instructions for use, explicit reference is made to the limited stability of the product.Too much force may lead to breakage or damage to the products.Therefore, only small, soft tissue areas/organs may be gripped and removed with the products.Chapter 8 of the instructions for use describes various checks and function tests which the user must carry out in order to detect possible damage to the product at an early stage and to be able to act accordingly.Possible hazards have been considered in the risk assessment b1-2 r03 with the corresponding extent of damage and probability of occurrence and evaluated with an acceptable risk.This evaluation is still valid even under consideration of the current case.Due to the defects / damage to the inner part, we assume mechanical overloading.There are no signs of a production or manufacturing defect.Richard wolf (b)(4) considers this matter closed.However, in the event (b)(4) receives any additional information a follow up report will be submitted to fda.
Event or Problem Description
On (b)(6) 2020 , a part of the insert of eragon bipolar forcep (83930031) broke off during an operation in the gynaecological hospital on the elbe.The broken part was recovered.

• Brand Name: ERAGON BIPOLAR
• Common Device Name: GRASP. FORCEPS INSERT Ø 5.5MM
• Manufacturer (Section D): RICHARD WOLF GMBH; pforzheimer street 32; knittlingen, 75438 ; GM 75438
• MDR Report Key: 10209320
• Report Number: 9611102-2020-00009
• Device Sequence Number: 11449588
• Product Code: HET
• UDI-Device Identifier: 04055207026526
• UDI-Public: 04055207026526
• Combination Product (Y/N): N
• Initial Reporter Country: GM
• PMA/510(K) Number: K033177
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Other
• Remedial Action: Replace
• Type of Report: Initial
• Report Date (Section B): 06/22/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Health Professional
• Device Model Number: 83930031
• Device Catalogue Number: 83930031
• Device Lot Number: 1376078
• Was Device Available for Evaluation?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 06/29/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention