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It was reported that, during thr surgery, it was noticed that, the end of a r3 depth gauge no longer has a hook to grab the bone.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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H10: after further assessment of the information gathered by the manufacturer, it was identified that this event should be re-evaluated for mdr reporting.The original information stated that during thr surgery, it was noticed that, the end of a r3 depth gauge no longer has a hook to grab the bone.The procedure was resumed, without any delay, using a s+n back-up device.Patient was not injured as consequence of this problem.However, after further clarification and information received, it was determined that the issue does not meet the criteria to be reportable.Moreover, if the device malfunction were to recur, it would not be likely to cause or contribute to a death or serious injury.While this event is no longer considered reportable, this report is being submitted as a courtesy to provide updated investigation results based on the return and evaluation of the complaint device subsequent to the submission of our previous report.The associated device was returned and evaluated.The visual inspection revealed that there is no evidence of a break of the hook.The device has obvious signs of wear.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 a similar event for the listed batch, this failure mode will be monitored for future complaints for any necessary corrective actions.A review of the risk management file 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 this product and event.At this time, we have no evidence to conclude that the product failed to meet any specifications at the time of manufacture.This device 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 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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