MAUDE Adverse Event Report: KARL STORZ SE & CO. KG STONE CRUSHING FORCEPS, SGL. ACTION JAWS

Model Number	27074B
Medical Device Problem Codes	Break (1069); Detachment of Device or Device Component (2907)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Correction in section h11.The event is filed under internal karl storz complaint id: (b)(4).
Additional Manufacturer Narrative
The device in question was returned to manufacturer.This information is reflected in section d9.The evaluation is anticipated, but not yet begun.The investigation will be performed by a designated karl storz employee.The event is filed under internal karl storz complaint id: (b)(4).
Event or Problem Description
According to the information received, after first use, the jaws were broken easily.According to the available picture, the pin of the joint and a piece near the pin are broken off.No patient involvement reported.No death or (unanticipated) serious deterioration in state of health reported.
Additional Manufacturer Narrative
Result of investigation: the device was sent to the manufacturer for inspection.During the manufacturer's technical inspection, the error description provided by the customer, "piece broken off", could be confirmed.The attachment/connector between the drawbar and the movable jaw is broken.Due to the age of the instrument and the presumed number of times it has been reprocessed, this can be attributed to wear and tear or user error.The material may have broken due to excessive force, which has altered its properties through use and cleaning.The event is filed under internal karl storz complaint id: (b)(4).

• Brand Name: STONE CRUSHING FORCEPS, SGL. ACTION JAWS
• Common Device Name: STONE CRUSHING FORCEPS, SGL. ACTION JAWS
• Manufacturer (Section D): KARL STORZ SE & CO. KG; dr.-karl-storz-strasse 34; tuttlingen, 78532 ; GM 78532
• Manufacturer (Section G): KARL STORZ SE & CO. KG; dr.-karl-storz-strasse 34; tuttlingen, 78532 ; GM 78532
• Manufacturer Contact: anja fair ; 2151 e grand ave; el segundo, CA 90245
• MDR Report Key: 22708608
• Report Number: 9610617-2025-01342
• Device Sequence Number: 18581835
• Product Code: OCZ
• UDI-Device Identifier: 04048551079386
• UDI-Public: 04048551079386
• Combination Product (Y/N): N
• Initial Reporter Country: TH
• PMA/510(K) Number: K950434
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,User Facility,Company Representative
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 01/27/2026

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: 27074B
• Device Catalogue Number: 27074B
• Device Lot Number: YP06
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 07/07/2025
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 07/17/2025
• Supplement Date Received by Manufacturer: 08/04/2025; 01/19/2026
• Initial Report FDA Received Date: 08/04/2025
• Supplement Report FDA Received Date: 08/05/2025; 01/27/2026
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• 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: Unknown
• Patient Sequence Number: 1
• Patient Sex: Unknown