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This is 1 of 3 reports linked to mfg report numbers: 3004608878-2026-00025 and 3004608878-2026-00026: a facility reported that the mayfield swivel adaptor (a1018) was part of a cervical stabilization case where the physician stated that the entire system felt like it slipped.The procedure was completed per usual with no injury to the patient, who is recovering as expected.Additionally, there was no surgical delay.
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The mayfield swivel adaptor (a1018) was returned for evaluation: device history record (dhr) review -the dhr shows no abnormalities related to the reported failure.Failure analysis - the evaluation shows that the swivel adapter has worn teeth on the swivel sleeve, and the washers and retaining rings are worn.Additionally, the unit was purchased in 2019 and has no service record; therefore, it is recommended for preventive maintenance (pm) service.To resolve the issues, the swivel sleeve, label, washers and retaining rings will be replaced along with general maintenance and cleaning.Root cause - the complaint is confirmed as the unit requires overhauling and replacement of damaged and worn components along with a pm service.The probable root cause is routine use/wear and lack of preventive maintenance.No further corrective action is required beyond the repairs based on the acceptability of risk and no adverse trends identified.This will be monitored and trended going forward.At present, we consider this complaint to be closed.
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