MAUDE Adverse Event Report: APPLIED MEDICAL RESOURCES ALEXIS LAPAROSCOPIC SYSTEM; RING (WOUND PROTECTOR), DRAPE RETENTION, INTERNAL

Model Number	C8502
Medical Device Problem Code	Device Contaminated During Manufacture or Shipping (2969)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	10/21/2024
Type of Reportable Event	Malfunction
Event or Problem Description
Name of procedure being performed: unknown.Detailed description of event: ai translated: 1.Ref c8502: alexis laparoscopic system m 5-9cm, a.Unsterile: hair found back in the sealed package.Please return what to do with these pieces.Our operations quarter has noticed that a hair got caught in a sterile packed product.Event description in pcf: when taking the alexis, they saw a hair in the package (see pictures).Patient status: patient is ok.Type of intervention: they took a new alexis.
Additional Manufacturer Narrative
No lot number has been provided, however; the event unit is anticipated to return.A follow-up report will be provided upon completion of the investigation.
Additional Manufacturer Narrative
The event unit was returned to applied medical for evaluation.Visual inspection confirmed the presence of a loose hair inside the pouch.Based on the condition of the returned unit and the description of the event, it is likely that the loose hair originated from an operator during the manufacturing process.Applied medical has performed a historical trend analysis and review of production records and no relevant documentations were identified.
Event or Problem Description
Name of procedure being performed: unknown detailed description of event: ai translated: attached are some pictures of damaged, normally sterile, material.Ref (b)(4): alexis laparoscopic system m 5-9 cm.Unsterile: hair found back in the sealed package.Please return what to do with these pieces.Our operations quarter has noticed that a hair got caught in a sterile packed product.Event description in pcf: when taking the alexis, they saw a hair in the package (see pictures).Patient status: patient is ok.Type of intervention: they took a new alexis.

• Brand Name: ALEXIS LAPAROSCOPIC SYSTEM
• Common Device Name: RING (WOUND PROTECTOR), DRAPE RETENTION, INTERNAL
• Manufacturer (Section D): APPLIED MEDICAL RESOURCES; 22872 avenida empresa; rancho santa margarita CA 92688
• Manufacturer Contact: ashleigh mendez ; 22872 avenida empresa; rancho santa margarita, CA 92688 ; 9497135359
• MDR Report Key: 20587419
• Report Number: 2027111-2024-00890
• Device Sequence Number: 8787613
• Product Code: KGW
• UDI-Device Identifier: 00607915119935
• UDI-Public: (01)00607915119935
• Combination Product (Y/N): N
• Initial Reporter Country: BE
• PMA/510(K) Number: EXEMPT
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,User Facility,Company Representative
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 01/03/2025

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Model Number: C8502
• Device Catalogue Number: 101357101
• Device Lot Number: 1518782
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 10/21/2024
• Supplement Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 11/01/2024
• Supplement Report FDA Received Date: 01/03/2025
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 04/05/2024
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Patient Sex: Unknown