MAUDE Adverse Event Report: GYRUS ACMI L.P. 10FR FIXEDPIN HEMOSTATIC PROBE

Model Number	CD-B612LA
Medical Device Problem Codes	Break (1069); Fracture (1260)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	03/25/2023
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The subject device was returned to the service center for evaluation; however, the device evaluation is still pending.Additionally, facility provided a photo of the subject device for evaluation.Supplemental report(s) will be submitted should any relevant new information is available and or received.Investigation is ongoing.This report will be supplemented accordingly following investigation.
Event or Problem Description
It was reported the device was used for a case (an unspecified procedure) and during the procedure, the sheath of bicoag probe was fractured around the site of duodenum before the user apply the heat energy.There was no adverse event reported.No harm or injury to patient was reported.No user injury reported due to the event.
Additional Manufacturer Narrative
This report is being supplemented to provide additional information based on response to follow up.Communication with the customer via company representative conveyed the following information: two cd-b612la devices failed in the same procedure.The failures were reported under patient identifier (b)(6) (lot kr206276) and patient identifier (b)(6) (lot kr200145).The procedure was a therapeutic upper gastrointestinal (gi) endoscopy.The intended procedure was completed with a third device (same model, different lot).No fragments fell into the patient's body.The reported failures did not affect the outcome of the procedure.It is unknown whether there was any delay in the procedure.No medical intervention as a result of the event.Investigation is ongoing.This report will be supplemented accordingly following investigation.
Additional Manufacturer Narrative
The initial medwatch incorrectly reported the site registration number.The site registration number is (b)(4).
Additional Manufacturer Narrative
This report is being supplemented to provide additional information based on the device evaluation and the legal manufacturer's final investigation.The device was returned and an evaluation was completed for it.During inspection, olympus confirmed the reported event, the gray sheath above the hemostasis tip was broken but not completely detached.One of the inner blue cables appeared to be intact, but the other one was severed.A review of the device history record found no deviations that could have caused or contributed to the reported issue.It has been over 1 year since the subject device was manufactured.Based on the results of the investigation, it is likely the sheath fracture occurred due to excessive force or the distal probe tip being subjected to blunt force against a hard object.However, a definitive root cause could not be determined.The following information is stated in the instructions for use (ifu): "do not use the device if resistance to insertion is encountered.Reduce the angle or lower the forceps elevator of the endoscope until the device passes smoothly; do not advance or extend the device abruptly; insert the device slowly.Abrupt insertion may cause damage to the endoscope or the device." in addition, page 3 of the ifu states ¿keep the device tip in sight during use.Inadvertent activation or movement of the device outside the field of vision may result in patient injury." olympus will continue to monitor field performance for this device.
Additional Manufacturer Narrative
This report is being submitted to correct the legal manufacturer¿s contact information and facility registration number.The facility registration number is 3011050570.
Additional Manufacturer Narrative
Correction: d3, g1, h11: this report is being submitted to correct the legal manufacturer¿s contact information and facility registration number.The facility registration number is 3011050570.

• Brand Name: 10FR FIXEDPIN HEMOSTATIC PROBE
• Common Device Name: HEMOSTATIC PROBE
• Manufacturer (Section D): GYRUS ACMI L.P.; 9600 louisiana avenue north; brooklyn park MN 55445
• Manufacturer (Section G): GYRUS ACMI L.P.; 9600 louisiana avenue north; brooklyn park MN 55445
• Manufacturer Contact: todd brill ; 800 west park drive; westborough, MA 01581 ; 5082077661
• MDR Report Key: 16778151
• Report Number: 3005975494-2023-00080
• Device Sequence Number: 6858389
• Product Code: KNS
• UDI-Device Identifier: 00821925039476
• UDI-Public: 00821925039476
• Combination Product (Y/N): N
• Initial Reporter Country: HK
• PMA/510(K) Number: K123319
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Other,Foreign,Health Professional,User Facility,Company Representative
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup,Followup,Followup,Followup
• Report Date (Section B): 06/21/2024

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: CD-B612LA
• Device Lot Number: KR206276
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 04/06/2023
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/27/2023
• Supplement Date Received by Manufacturer: 04/21/2023; 05/01/2023; 07/25/2023; 06/18/2024; 06/21/2024
• Initial Report FDA Received Date: 04/20/2023
• Supplement Report FDA Received Date: 05/15/2023; 05/18/2023; 08/02/2023; 06/18/2024; 06/21/2024
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 05/05/2022
• 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