MAUDE Adverse Event Report: STRYKER ENDOSCOPY-SAN JOSE SERFAS 50-S SWEEP + XL; ELECTROSURGICAL, CUTTING & COAGULATION & ACCESSORIES

Model Number	0279351653
Health Effect - Clinical Codes	Insufficient Information (4580); No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	04/07/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Additional information will be provided once the investigation has been completed.
Event or Problem Description
It was reported that a piece of the device broke off during the procedure.The piece was removed.
Event or Problem Description
It was reported that a piece of the device broke off during the procedure.The piece was removed.
Additional Manufacturer Narrative
Alleged failure: during a iliopsoas release on a total hip the white portion of the rf wand chipped off while the wand was activated.The wand was successfully used for around 40 min prior to this happening.The failure(s) identified in the investigation is consistent with the complaint record.The probable root cause/s could be 1) excessive force used when inserting removing the probe, a probe inserted into an obstructed passageway, or any forceful impact to the tip of the probe with rigid objects.The probe is used as a tool for a mechanical displacement of tissue or bone, or to pry or scrub.The product was returned for investigation and the failure mode will be monitored for future reoccurrence.

• Brand Name: SERFAS 50-S SWEEP + XL
• Common Device Name: ELECTROSURGICAL, CUTTING & COAGULATION & ACCESSORIES
• Manufacturer (Section D): STRYKER ENDOSCOPY-SAN JOSE; 5900 optical court; san jose CA 95138
• MDR Report Key: 11783187
• Report Number: 0002936485-2021-00242
• Device Sequence Number: 1021435
• Product Code: GEI
• UDI-Device Identifier: 07613327405828
• UDI-Public: 07613327405828
• Combination Product (Y/N): N
• Initial Reporter State: CO
• Initial Reporter Country: US
• PMA/510(K) Number: K171391
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 07/06/2021

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
• Operator of Device: Health Professional
• Device Model Number: 0279351653
• Device Catalogue Number: 0279351653
• Device Lot Number: 21043AE2
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 04/21/2021
• Initial Date Received by Manufacturer: 04/07/2021
• Supplement Date Received by Manufacturer: 04/07/2021
• Initial Report FDA Received Date: 05/06/2021
• Supplement Report FDA Received Date: 07/06/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1