MAUDE Adverse Event Report: KARL STORZ SE & CO. KG LIGHT CABLE, 3.5MM X 300CM. LGTH 9.8 FT

Model Number	495ND
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Burn(s) (1757)
Date of Event	08/11/2020
Type of Reportable Event	Serious Injury
Event or Problem Description
An elderly patient undergoing laproscopic hysterectomy w/ bilateral salpingo-oophorectomy and pelvic washings.The patient was placed in lithotomy, prepped and draped.The team began to set up the scope, camera and light source.The resident reports forgetting to connect the light source to the scope prior to requesting the power source machine be turned on by the nurse.While the light source was resting of the resident.Shortly thereafter, a small hole was noted in the drapes and two smalls (approximately 0.5 cm in diameter) darkened, blistered lesions, believed to be 2nd degree burns, were identified on the patient's right forearm.
Additional Manufacturer Narrative
The previous reportability decision was reversed based on a retrospective review.The event is filed under internal karl storz complaint id: (b)(6).

• Brand Name: LIGHT CABLE, 3.5MM X 300CM. LGTH 9.8 FT
• Common Device Name: LIGHT CABLE
• Manufacturer (Section D): KARL STORZ SE & CO. KG; dr.-karl-storz-strasse 34; tuttlingen, 78532 ; GM 78532
• MDR Report Key: 17243565
• Report Number: 2020550-2023-00143
• Device Sequence Number: 20042458
• Product Code: FCW
• UDI-Device Identifier: 04048551168899
• UDI-Public: 4048551168899
• Combination Product (Y/N): N
• Initial Reporter State: MA
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Importer
• Initial Reporter Occupation: Risk Manager
• Type of Report: Initial
• Report Date (Section B): 06/30/2023
• Report Date (Section F): 04/01/2021

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: 495ND
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: Yes
• Distributor Facility Aware Date: 05/07/2023
• Event Location: Hospital
• Date Report to Manufacturer: 05/07/2021
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 06/30/2023
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other
• Patient Sex: Female
• Date Report Sent to FDA: 04/01/2021