MAUDE Adverse Event Report: MEDLINE INDUSTRIES, LP Medline Industries, Inc.; FHSH LAP CHOLE PACK-LF

Model Number	DYNJ61123B
Medical Device Problem Code	Material Integrity Problem (2978)
Health Effect - Clinical Code	Foreign Body Reaction (1868)
Date of Event	01/23/2023
Type of Reportable Event	Serious Injury
Event or Problem Description
According to the facility, "the rfid from the sponge fell out into the patient and the surgeon had to pull it out before closing".
Additional Manufacturer Narrative
According to the facility, "the rfid from the sponge fell out into the patient and the surgeon had to pull it out before closing".No additional information is available at this time.The sample has been requested, but has not been returned for evaluation.It has been determined that the reported event caused or contributed to serious injury requiring medical intervention, therefore, this medwatch is being filed.If any further relevant information is identified or obtained, a supplemental medwatch will be submitted.

• Brand Name: Medline Industries, Inc.
• Common Device Name: FHSH LAP CHOLE PACK-LF
• Manufacturer (Section D): MEDLINE INDUSTRIES, LP; three lakes drive; northfield IL 60093
• Manufacturer Contact: justin herrmann ; three lakes drive; northfield, IL 60093
• MDR Report Key: 16335399
• Report Number: 1423395-2023-00004
• Device Sequence Number: 6845934
• Product Code: FDE
• UDI-Device Identifier: 10195327047313
• UDI-Public: 10195327047313
• Combination Product (Y/N): N
• Initial Reporter State: CA
• 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
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 02/09/2023

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?: No
• Operator of Device: Health Professional
• Device Model Number: DYNJ61123B
• Device Catalogue Number: DYNJ61123B
• Device Lot Number: 22JME959
• Was Device Available for Evaluation?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 01/23/2023
• Initial Report FDA Received Date: 02/09/2023
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• 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
• Outcome Attributed to Adverse Event: Other
• Patient Sex: Unknown