MAUDE Adverse Event Report: NISSHA MEDICAL TECHNOLOGIES LTD BOSTON SCIENTIFIC; ELECTROSURGICAL, CUTTING & COAGULATION & ACCESSORIES

Model Number	DGP-PM2-25
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Burn(s) (1757)
Date of Event	11/16/2022
Type of Reportable Event	Serious Injury
Event or Problem Description
It was reported that the patient had a burn from the grounding pad.The grounding pad was discarded.
Event or Problem Description
It was reported that the patient had a burn from the grounding pad.The grounding pad was discarded.
Additional Manufacturer Narrative
Correction to the initial and follow-up 1 mdrs in block b5.
Event or Problem Description
It was reported that the patient had a burn from the grounding pad.The grounding pad was discarded.No medical treatment outside of the clinic was provided.
Event or Problem Description
It was reported that the patient had a burn from the grounding pad.The grounding pad was discarded.No medical treatment outside of the clinic was provided.
Additional Manufacturer Narrative
This 3500a mdr was submitted in error.The regulatory reporting for this device is the responsibility of the manufacturer (nissha medical technologies ltd.) and not boston scientific.Therefore, please note that this event should not have been reported on a 3500a mdr form by boston scientific.

• Brand Name: BOSTON SCIENTIFIC
• Common Device Name: ELECTROSURGICAL, CUTTING & COAGULATION & ACCESSORIES
• Manufacturer (Section D): NISSHA MEDICAL TECHNOLOGIES LTD; torbay business park; woodview road; paignton TQ4 7 HP; UK TQ4 7HP
• Manufacturer Contact: erik sherburne ; 25155 rye canyon loop; valencia, CA 91355 ; 7632920920
• MDR Report Key: 16080819
• Report Number: 3006630150-2022-07419
• Device Sequence Number: 6275464
• Product Code: GEI
• UDI-Device Identifier: 35060441917622
• UDI-Public: 35060441917622
• Combination Product (Y/N): N
• Initial Reporter State: AZ
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Health Professional,Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup,Followup
• Report Date (Section B): 09/15/2024

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Model Number: DGP-PM2-25
• Device Catalogue Number: DGP-PM2-25
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 12/05/2022
• Supplement Date Received by Manufacturer: 01/04/2023; 04/26/2023; 09/12/2024
• Initial Report FDA Received Date: 12/30/2022
• Supplement Report FDA Received Date: 01/24/2023; 04/28/2023; 09/15/2024
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• 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
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Sex: Unknown