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During surgery for a bilateral cochlear implantation case, the surgeon opened an intact, sealed med-el cochlear implant intended for insertion in the left ear.Prior to handing over the implant to the surgeon the audiology team performed in-package telemetry as per standard protocol.At that time, the in package telemetry results were completely normal, and no abnormality was detected.However, upon opening the implant box in the ot and while preparing the device for surgical insertion, it was observed that the internal magnet was loose and became automatically expelled from its housing without any manual force or manipulation.The implant had not yet been handled for placement.Immediately after identifying the issue, the implant was not used.The device was carefully kept in its original box in the same condition as observed.To proceed with the surgery and ensure user safety, the alternate implant that was originally planned for the contralateral ear was used instead.No attempt was made to reinsert or manipulate the expelled magnet.
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