MAUDE Adverse Event Report: MEDTRONIC XOMED INC. TRICUT 4MM 27.5CM LONG - ANGLE-TIP LARYNGEAL; BUR, EAR, NOSE AND THROAT

Model Number	1884030
Medical Device Problem Codes	Break (1069); Material Separation (1562)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	06/16/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Note: this is the same event reported in regulatory report #: 1045254-2021-00559.If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
A health care provider reported via manufacturer representative that the blades have broken at the level of the angulation.There were no broken pieces of the reported product remain inside the patient's body.There was no intervention performed and no delay in the procedure.There was no patient injury.
Additional Manufacturer Narrative
H6: the fdd a0401 and fdm b17 no longer applies.Medtronic is submitting this report to comply with fda reporting regulations under 21 cfr parts 4 and 803.This report is based upon information obtained by medtronic, which the company may not have been able to fully investigate or verify prior to the date the report was required by the fda.Medtronic has made reasonable efforts to obtain more complete information and has provided as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.In particular, this report does not constitute an admission by anyone that the product described in this report has any ¿defects¿ or has ¿malfunctioned¿.These words are included in the fda 3500a form and are fixed items for selection created by the fda to categorize the type of event solely for the purpose of regulatory reporting.Medtronic objects to the use of these words and others like them because of the lack of definition and the connotations implied by these terms.This statement should be included with any information or report disclosed to the public under the freedom of information act.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.A good faith effort will be made to obtain the applicable information relevant to the report.If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
On follow up, it was reported that the blades broke in 2 parts.The blades were used in the same case.There were no fragments that came off or got detached from the broken device.The blades broke in the middle part while trying to remove from the handpiece.There were no fragments that get in contact with the patient.

• Brand Name: TRICUT 4MM 27.5CM LONG - ANGLE-TIP LARYNGEAL
• Common Device Name: BUR, EAR, NOSE AND THROAT
• Manufacturer (Section D): MEDTRONIC XOMED INC.; 6743 southpoint dr n; jacksonville FL 32216
• MDR Report Key: 12590976
• Report Number: 1045254-2021-00560
• Device Sequence Number: 4079964
• Product Code: EQJ
• UDI-Device Identifier: 00681490047623
• UDI-Public: 00681490047623
• Combination Product (Y/N): N
• Initial Reporter Country: FR
• PMA/510(K) Number: EXEMPT
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 11/02/2021

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: 1884030
• Device Catalogue Number: 1884030
• Device Lot Number: 0218669516
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 08/02/2021
• Supplement Date Received by Manufacturer: 10/15/2021
• Initial Report FDA Received Date: 10/07/2021
• Supplement Report FDA Received Date: 11/02/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1