MAUDE Adverse Event Report: INMODE LTD. FRACTORA; GEI

Model Number	AG601261A
Medical Device Problem Code	Improper or Incorrect Procedure or Method (2017)
Health Effect - Clinical Codes	Burn(s) (1757); Scar Tissue (2060); Skin Infection (4544)
Date of Event	08/11/2018
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Following internal capa opened at inmode, voluntary reports previously submitted by inmode to fda were reviewed retrospectively.Previous voluntary report (mw5092685) was re-assessed and is reported now again as mandatory.Technical inspection of the device and the handpiece revealed no technical issues.Investigation attributed the root cause to a user error: incorrect technique, not congruent with ifu, causing the burns.Contamination was due to lack of aseptic conditions post treatment and is not related to the device.The physician was retrained.
Event or Problem Description
Burns on face with subsequent contamination.Residual indentations 3 months post treatment.

• Brand Name: FRACTORA
• Common Device Name: GEI
• Manufacturer (Section D): INMODE LTD.; tavor building (pob 533); shaar yokneam; yokneam northern, north 20692 06; IS 2069206
• Manufacturer (Section G): INMODE LTD.; tavor building (pob 533); shaar yokneam; yokneam northern, north 20692 06; IS 2069206
• Manufacturer Contact: lina korsensky ; tavor building (pob 533); shaar yokneam; yokneam northern, north 20692-06 ; IS 2069206
• MDR Report Key: 17648619
• Report Number: 3010511300-2018-00821
• Device Sequence Number: 6457250
• Product Code: GEI
• UDI-Device Identifier: 07290016633054
• UDI-Public: 07290016633054
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: K151273
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional,User Facility,Company Representative
• Initial Reporter Occupation: Physician
• Remedial Action: Other,Notification,Patient Monitoring
• Type of Report: Initial
• Report Date (Section B): 08/30/2023

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: AG601261A
• Device Catalogue Number: AG601261A
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 10/08/2018
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 08/21/2018
• Initial Report FDA Received Date: 08/30/2023
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 09/05/2011
• 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
• Outcome Attributed to Adverse Event: Other
• Patient Age: 20 YR
• Patient Sex: Female
• Patient Ethnicity: Non Hispanic
• Patient Race: White