|
It was reported that, during an internal fixation surgery while drilling, the end of one (1) 2.0/2.7mm double-ended drill guide broke off outside of patient.It was confirmed that no fragments fell inside the wound.The procedure was resumed, without any delay, using an equivalent s+n back-up.No further complications were reported.
|
|
H11: additional information reviewed by the manufacturer has identified that this event should be re-evaluated for mdr reporting.The new information states that a visual inspection of the returned device finds the device returned with one end of the device out of place, therefore, event may cause minor or temporary injury requiring no or minor medical intervention.Event may result in a short procedural delay and/or require use of a backup device to continue procedure.This event is not likely to cause or contribute to a death or serious injury and is considered not reportable pursuant to applicable regulations.If additional details confirm the occurrence of a reportable event, we will update our records accordingly and submit a subsequent report detailing both the event and our completed investigations.H3, h6: the associated device was returned and evaluated.A visual inspection of the returned device finds the device returned with an unidentified drill bent almost 90° with one end of the device out of place and on the bent drill.The device is worn from use.No further testing can be conducted since there is damage hindering inspection/evaluation.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 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.According to the inspection drawing, the threads are secured with loctite.Therefore, it can be concluded that the adhesive compound has failed due to repeated use, as it was unable to maintain the bond between the threads and the frame.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.
|