MAUDE Adverse Event Report: Medline Industries, LP MEDLINE; PENCIL, CAUTERY, ROCKER, PTFE

Catalog Number	ESRK3002P
Medical Device Problem Code	Energy Output Problem (1431)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	08/15/2023
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that "coagulation part of the pen was fine, but the cutting part would not work at all.".
Additional Manufacturer Narrative
The customer reported that the coagulation part of the pen was fine, but the cutting part would not work at all.Medline quality received 1 ea for evaluation, and a functional inspection was conducted with the provided sample; the sample was plugged into a bovie generator and functioned properly when using cut mode.The reported concern could not be confirmed, as the sample functioned normally on cutting mode, and the cause was documented as not confirmed with received sample.A retrospective review of the past year indicated that there have been no prior complaints in regard to this issue, and the division will continue to monitor this issue for trending.There were no reports of death, serious injury, medical intervention, or follow up care.It has been determined that the reported event could cause or contribute to serious injury if it were to occur again.In an abundance of caution, this is a reportable event.If additional information becomes available this report will be reopened and reevaluated.This medical device report (mdr) is being submitted as part of retrospective review activities, which include review of historical data in accordance with regulations at 21 cfr part 803.The information included in this mdr reflects the information reasonably known to the manufacturer at the time of this retrospective review and submission.

• Brand Name: MEDLINE
• Common Device Name: PENCIL, CAUTERY, ROCKER, PTFE
• Manufacturer (Section D): Medline Industries, LP; three lakes drive; northfield IL 60093 -275
• Manufacturer Contact: sasidhar lakku ; three lakes drive; northfield, IL 60093--275
• MDR Report Key: 50691585
• Report Number: 1417592-2026-34720
• Device Sequence Number: 18555284
• Product Code: GEI
• UDI-Device Identifier: 30193489017735
• UDI-Public: 30193489017735
• Combination Product (Y/N): N
• Initial Reporter State: PA
• Initial Reporter Country: US
• PMA/510(K) Number: K040780
• 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): 09/09/2026

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: ESRK3002P
• Device Lot Number: 09522010006
• Was Device Available for Evaluation?: Yes
• Date Returned to Manufacturer: 08/18/2023
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 08/15/2023
• Initial Report FDA Received Date: 09/09/2026
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Sex: Unknown