MAUDE Adverse Event Report: OLYMPUS WINTER & IBE GMBH JAWS "HIQ+", BIPOLAR, 5 X 330 MM, PREPARATION FORCEPS, MARYLAND, SHORT

Model Number	WA64320C
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	08/02/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
During inspection and testing, the teflon body was damaged by burns.And the proximal end was deformed.A review of the device history record found no deviations, that could have caused or contributed to the reported event.Based on the results of the legal manufacturer's investigation, the damaged teflon body was likely, caused by wrong handling by the user.The damage was most likely, caused by a massive high-frequency current flashover.This may be triggered by unintentional contact with other equipment, or by permanent contact between the distal jaws without tissue contact, during a high-frequency application.This leads to a short circuit inside the device.The deformed proximal end was likely, caused by wrong handling.More specifically, subjecting the device to excessive force.The deformation of the proximal end is most likely, attributable to improper combination of the jaws insert and to the use of excessive force by the customer.It was still possible, to combine the jaws insert.However, due to the degree of the deformation, it can no longer be guaranteed that the overload protection mechanism is triggered safely and properly.Olympus will continue to monitor field performance for this device.
Event or Problem Description
Olympus was informed, that seven (7) hiq+ bipolar maryland graspers broke while performing total laparoscopic hysterectomy (tlh) surgeries.During the past year, all seven (7) are separate events.It was reported, on some of the graspers, sparking was observed, on the tip when using with an electrosurgical generator.No device component or fragment fell inside the patient.There was only a 3¿5 minute delay to replace the device.As the intended procedures were completed with another like model grasper.The device was inspected before use by the nurse, prior to the surgery.No death or injury and no harm or impact to patient or other was reported to olympus.The first event is reported under patient identifier (b)(6), the second event is reported under patient identifier (b)(6), the third event is reported under patient identifier (b)(6) (this report), the fourth event is reported under patient identifier (b)(6), the fifth event is reported under patient identifier (b)(6), the sixth event is reported under patient identifier (b)(6) the seventh event is reported under patient identifier (b)(6), the subject device was sent back to olympus for evaluation.During inspection and testing, the subject device was found to have damaged insulation.This report is being submitted for the malfunction found during evaluation.

• Brand Name: JAWS "HIQ+", BIPOLAR, 5 X 330 MM, PREPARATION FORCEPS, MARYLAND, SHORT
• Common Device Name: FORCEPS
• Manufacturer (Section D): OLYMPUS WINTER & IBE GMBH; kuehnstrasse 61; hamburg, hamburg 22045 ; GM 22045
• Manufacturer (Section G): OLYMPUS WINTER & IBE GMBH; kuehnstrasse 61; hamburg, hamburg 22045 ; GM 22045
• Manufacturer Contact: todd brill ; 800 west park drive; westborough, MA 01581 ; 5082077661
• MDR Report Key: 17010653
• Report Number: 9610773-2023-01454
• Device Sequence Number: 15344957
• Product Code: GEI
• UDI-Device Identifier: 04042761062442
• UDI-Public: 04042761062442
• Combination Product (Y/N): N
• Initial Reporter Country: CE
• PMA/510(K) Number: K984417
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Other,Foreign,User Facility,Company Representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 05/26/2023

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: WA64320C
• Device Catalogue Number: WA64320C
• Device Lot Number: 19YW-0028
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 03/03/2023
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 01/31/2023
• Initial Report FDA Received Date: 05/26/2023
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 11/01/2019
• Is the Device Labeled for Single Use? (Y/N): No
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Reuse
• Patient Sequence Number: 1
• Patient Sex: Unknown