MAUDE Adverse Event Report: Tri-State DE Mexico, S. DE R.L. DE C.V Medline; SKIN STAPLE REMOVER

Catalog Number	DYNJ04058A
Medical Device Problem Code	Difficult to Open or Close (2921)
Health Effect - Clinical Code	Pain (1994)
Date of Event	06/30/2026
Type of Reportable Event	Malfunction

• Brand Name: Medline
• Common Device Name: SKIN STAPLE REMOVER
• Manufacturer (Section D): Tri-State DE Mexico, S. DE R.L. DE C.V; calzada presidente venustiano; carranza #301; mexicali, baja california 21397 ; MX 21397
• Manufacturer Contact: nithla mathivanan ; three lakes drive; northfield, IL 60093--275
• MDR Report Key: 50228845
• Report Number: 3004519921-2026-00061
• Device Sequence Number: 21426061
• Product Code: KDC
• UDI-Device Identifier: 10653160385769
• UDI-Public: 10653160385769
• Combination Product (Y/N): N
• Initial Reporter State: IL
• Initial Reporter Country: US
• PMA/510(K) Number: Exempt
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Type of Report: Initial
• Report Date (Section B): 08/12/2026

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
• Device Catalogue Number: DYNJ04058A
• Device Lot Number: 2026010690
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 07/16/2026
• Initial Report FDA Received Date: 08/12/2026
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 01/13/2026
• 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