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Model Number G22647
Device Problems Retraction Problem (1536); Failure to Advance (2524)
Patient Problem No Consequences Or Impact To Patient (2199)
Event Date 11/05/2020
Event Type  malfunction  
Manufacturer Narrative
Initial reporter; occupation: other healthcare professional: tech. Pma/510(k) # k191048. Investigation evaluation: the device said to be involved was returned in an open pouch from the same lot number provided in the report. The label matches the products returned. Our laboratory evaluation of the product said to be involved could not confirm the report as it was described. The handle of the device was manipulated and the snare head would open and close with no resistance felt. During a visual inspection of the device, there was no damage noted on the device. The continuity from the electrical pin to the snare head was tested with an ohm meter and passed. An additional functional test with the device was performed by attaching the active cord to the electrical pin. The active cord connected to the device easily and remained securely connected. The device was connected to a valley lab generator and power was applied. The snare cut simulated tissue as expected. A lab meeting was held with production and no defects were found after a visual and functional evaluation of the device. The device history record for the lot number said to be involved was reviewed. The device history record contains nonconformances that could potentially be related to this report. The device goes through different inspections prior to leaving the facility. These inspections would have removed any nonconforming devices prior to distribution. A discrepancy or anomaly was not observed with the product that was released for distribution. Investigation conclusion: a definitive cause for the reported observation could not be determined because the product said to be involved functioned as intended. A discrepancy or anomaly that could have contributed to the reported observation was not observed during our laboratory analysis of the returned product. The instructions for use contains the following information to assist with proper setup and use of the device: "fully retract and extend snare to confirm smooth operation of device. " prior to distribution, all acusnare polypectomy snares are subjected to a visual inspection and functional testing to ensure device integrity. A review of the device history record confirmed that the lot said to be involved met all manufacturing requirements prior to shipment. Corrective action: a review of the complaint history was conducted. The likelihood of occurrence is considered rare. Corrective action is not warranted at this time based on the quality engineering risk assessment. Quality assurance will continue to monitor for complaint trends and reassess the risk assessment results as post market feedback continues to become available.
Event Description
During an endoscopic polypectomy, the physician used a cook acusnare polypectomy snare and there was resistance in opening and closing the device [difficulty with retraction subject of report]. A new device was opened and used to complete the intended procedure successfully. " a section of the device did not remain inside the patient¿s body. The patient did not require any additional procedures due to this occurrence. According to the initial reporter, the patient did not experience any adverse effects due to this occurrence.
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Manufacturer (Section D)
4900 bethania station rd
winston-salem NC 27105
Manufacturer (Section G)
4900 bethania station rd
winston-salem NC 27105
Manufacturer Contact
scottie fariole
4900 bethania station rd
winston-salem, NC 27105
MDR Report Key10935059
MDR Text Key234325702
Report Number1037905-2020-00518
Device Sequence Number1
Product Code FDI
Combination Product (y/n)N
Reporter Country CodeUS
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type company representative
Reporter Occupation
Type of Report Initial
Report Date 12/02/2020
1 Device was Involved in the Event
0 Patients were Involved in the Event:
Date FDA Received12/02/2020
Is this an Adverse Event Report? No
Is this a Product Problem Report? Yes
Device Operator
Device Model NumberG22647
Device Catalogue NumberASDB-15-015-S
Device Lot NumberW4354297
Was Device Available for Evaluation? Device Returned to Manufacturer
Date Returned to Manufacturer11/17/2020
Is the Reporter a Health Professional?
Was the Report Sent to FDA?
Event Location No Information
Date Manufacturer Received11/05/2020
Was Device Evaluated by Manufacturer? Yes
Date Device Manufactured06/12/2020
Is the Device Single Use? Yes
Is This a Reprocessed and Reused Single-Use Device? No
Type of Device Usage Initial