MAUDE Adverse Event Report: DEROYAL INDUSTRIES, INC. DEROYAL; GAUZE/SPONGE, INTERNAL

Model Number	30-154
Health Effect - Clinical Code	Insufficient Information (4580)
Date of Event	02/23/2022
Type of Reportable Event	Malfunction
Event or Problem Description
During procedure, 1/4 x 1/4 neuro patties were used.The surgical technologist noted that the x-ray detectable line in a patty had fallen off onto the surgical back table after the patty was removed from the patient.

• Brand Name: DEROYAL
• Common Device Name: GAUZE/SPONGE, INTERNAL
• Manufacturer (Section D): DEROYAL INDUSTRIES, INC.; 200 debusk lane; powell TN 37849
• MDR Report Key: 13807898
• Report Number: 13807898
• Device Sequence Number: 11283460
• Product Code: EFQ
• UDI-Device Identifier: 00749756037808
• UDI-Public: (01)00749756037808
• Combination Product (Y/N): N
• Initial Reporter State: RI
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: User Facility
• Initial Reporter Occupation: Risk Manager
• Type of Report: Initial
• Report Date (Section B): 03/03/2022
• Report Date (Section F): 03/03/2022

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: 30-154
• Device Catalogue Number: 30-154
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: Yes
• Event Location: Hospital
• Date Report to Manufacturer: 03/18/2022
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 03/18/2022
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Unknown
• Patient Sequence Number: 1
• Patient Sex: Female
• Date Report Sent to FDA: 03/03/2022