MAUDE Adverse Event Report: KARL STORZ SE & CO. KG FIVE S 3.5X65, STERILE, FOR SINGLE USE,; FIVE S, LARYNGOSCOPE

Model Number	091361-06
Medical Device Problem Code	Material Separation (1562)
Health Effect - Clinical Code	Insufficient Information (4580)
Date of Event	05/24/2023
Type of Reportable Event	Serious Injury
Event or Problem Description
It was reported that the scope was used for an awake fibre-optic intubation the camera tip broke off and went missing during bronchoscopy.The bronchoscope was already in the trachea, but the et tube struggled to railroad through the mass lesion at the vocal cords.The scope was pulled back to confirm the position of the et tube, but the picture went blurry and did not clear with suctioning.The patient started to desaturate.The scope was retracted, and the ventilation was initiated.The scope was checked for completeness, and it was discovered that the camera tip was absent.After the procedure, the tip was found on the floor.The intubation was unsuccessfully, and a tracheostomy needs to be performed.The cause of the tracheostomy is unknown, but due to the steps taken and the additional treatment, this case was deemed reportable.
Additional Manufacturer Narrative
The affected device has been requested for investigation by the manufacturer.Device was not yet returned for investigation.The event is filed under internal karl storz complaint id: (b)(4).
Additional Manufacturer Narrative
The kind and amount of damage (sharp deformation on shaft ~70mm from distal side, the shaft is deformed oval in entire length between ~35 - 300mm from distal side, vertebrae shows deformation under distal rubber joint vertebrae- shaft is loose and rotating freely.Vertebrae moved out form shaft ~1mm) found during investigation indicates that the endoscope has been exposed to inappropriate forces, ignoring the correct handling given in the ifu.The event is filed under internal karl storz complaint id: (b)(4).

• Brand Name: FIVE S 3.5X65, STERILE, FOR SINGLE USE,
• Common Device Name: FIVE S, LARYNGOSCOPE
• Manufacturer (Section D): KARL STORZ SE & CO. KG; dr.-karl-storz-strasse 34; tuttlingen, 78532 ; GM 78532
• Manufacturer (Section G): KARL STORZ SE & CO. KG; dr.-karl-storz-strasse 34; tuttlingen, 78532 ; GM 78532
• Manufacturer Contact: anja fair ; 2151 e grand ave; el segundo, CA 90245
• MDR Report Key: 17117788
• Report Number: 9610617-2023-00128
• Device Sequence Number: 17804584
• Product Code: CAL
• UDI-Device Identifier: 04048551422519
• UDI-Public: 4048551422519
• Combination Product (Y/N): N
• Initial Reporter Country: SF
• PMA/510(K) Number: EXEMPT
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,Company Representative
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 12/01/2023

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?: Yes
• Operator of Device: Health Professional
• Device Model Number: 091361-06
• Device Catalogue Number: 091361-06
• Device Lot Number: 100080554
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 05/26/2023
• Supplement Date Received by Manufacturer: 11/02/2023
• Initial Report FDA Received Date: 06/13/2023
• Supplement Report FDA Received Date: 12/01/2023
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• 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: Unknown
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Sex: Unknown