MAUDE Adverse Event Report: APPLIED MEDICAL RESOURCES CTR03, 5X100 KII OPT ZTHR 6/BX; LAPAROSCOPE, GENERAL & PLASTIC SURGERY

Model Number	CTR03
Medical Device Problem Code	Device Contaminated During Manufacture or Shipping (2969)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	09/20/2022
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The event device is anticipated to return.A follow-up report will be provided upon completion of the investigation.
Event or Problem Description
Name of procedure being performed na (incoming inspection).Detailed description of event, [facility] incoming inspection (b)(4).This is a complaint from [facility] evaluation team.The lot mentioned above was found to have defective units per our incoming inspection.Delivery date: (b)(6), 2022.We found the defects that already informed applied medical by cer.We just inform you the defect and return the products for the following defects.You do not need an investigation.Hairlike object in pouch: ctr03 lot #1460640 (1 ea.) product available for return.Type of intervention: na (incoming inspection).Patient status: na (no patient involvement).
Additional Manufacturer Narrative
The event unit was returned to applied medical for evaluation.Visual inspection confirmed the presence of hair inside the sterile unopened pouch.Based on the condition of the returned unit and the description of the event, the hair likely originated from an operator during the manufacturing process.
Event or Problem Description
Name of procedure being performed na (incoming inspection).Detailed description of event [distributor] incoming inspection (b)(4).This is a complaint from [distributor] evaluation team.The lot mentioned above was found to have defective units per our incoming inspection.Delivery date: september 16,2022.Please refer to the attachment file.I) we found the defects that already informed applied medical by cer.We just inform you the defect and return the products for the following defects.You do not need investigation.Hairlike object in pouch - ctr03 lot #1460640 (1 ea.).Product available for return.Type of intervention: na (incoming inspection).Patient status: na (no patient involvement).

• Brand Name: CTR03, 5X100 KII OPT ZTHR 6/BX
• Common Device Name: LAPAROSCOPE, GENERAL & PLASTIC SURGERY
• Manufacturer (Section D): APPLIED MEDICAL RESOURCES; 22872 avenida empresa; rancho santa margarita CA 92688
• Manufacturer Contact: aaron fulcher ; 22872 avenida empresa; rancho santa margarita, CA 92688 ; 9497135765
• MDR Report Key: 15763928
• Report Number: 2027111-2022-00812
• Device Sequence Number: 6227211
• Product Code: GCJ
• UDI-Device Identifier: 00607915123482
• UDI-Public: (01)00607915123482(17)250808(30)01(10)1460640
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K060096
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Foreign,Distributor
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 12/27/2022

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: Other
• Device Expiration Date: 08/08/2025
• Device Model Number: CTR03
• Device Catalogue Number: 101138201
• Device Lot Number: 1460640
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 10/14/2022
• Supplement Date Received by Manufacturer: 10/14/2022
• Initial Report FDA Received Date: 11/09/2022
• Supplement Report FDA Received Date: 12/27/2022
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 08/09/2022
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Patient Sex: Unknown