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It was reported that during a clavicle internal fixation, the 2.0mm drill short w/ao qc broke in the 2.0/2.7mm double-ended drill guide and could not separate.All pieces were accounted for.The procedure was resumed, without any delay, using a s+n back-up device.Patient was not injured as consequence of this problem.
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H3, h6: the device was not returned for evaluation; therefore, a device analysis could not be performed.For the drill short w/ao qc, device batch number was not provided, thus, an evaluation of the manufacturing records could not be performed.A review of complaint history of the previous 12 months revealed similar events for the listed device, this failure mode will be monitored for future complaints for any necessary corrective actions.For the double-ended drill guide, a review of the production order did not reveal a manufacturing abnormality that could have caused or contributed to the reported incident.A review of complaint history based on the historical data revealed similar events for the listed batch, this failure mode will be monitored for future complaints for any necessary corrective actions.A review of the risk management files revealed this failure mode was previously identified.The anticipated risk level is still adequate.A historical review concluded that there are no prior actions related to these products and event.At this time, we have no reason to suspect that the products failed to meet any specifications at the time of manufacture.For the drill short w/ao qc, this is a single use device, surgical technique or damage from misuse are likely potential factors that could contribute to the reported event.The double-ended drill guide, is a single use device, surgical technique or damage from misuse are likely potential factors that could contribute to the reported event.The double ended drill guide is a reusable instrument that can be exposed to numerous surgeries.Damage from prolonged use, misuse or rough handling are likely potential factors that could contribute to the reported event.We recommend that all reusable instruments be routinely inspected for wear and damage and replaced as necessary.Based on this investigation, the need for corrective action is not indicated.Should the devices or additional information be received, the complaint will be reopened.No further investigation is warranted for this complaint; however, we will continue to monitor for future complaints and investigate as necessary.We consider this investigation closed.
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