MAUDE Adverse Event Report: Medline Industries, LP MEDLINE; DBD-LAMINECTOMY 676786-V-LF

Catalog Number	DYNJ58506G
Medical Device Problem Code	Detachment of Device or Device Component (2907)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	10/05/2023
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that clear plastic piece came off cautery tip during procedure.
Additional Manufacturer Narrative
The account reported finding clear piece came off cautery tip, and the complaint stated, "patient: not harmed." no sample or photo received for our investigation; finished good production records and finished good pack build were reviewed, and there were no line down situations, run without approvals, deviations, non-conformance reports, or issues with the build that likely contributed to the reported issue.We were unable to confirm the reported defect as there was no samples or detailed pictures that were received for this complaint investigation, and without a sample it is difficult to determine a true root cause for the reported issue.This complaint has been provided to the vendor for further evaluation, and the supplier quality team will also monitor this issue for trending purposes.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: DBD-LAMINECTOMY 676786-V-LF
• Manufacturer (Section D): Medline Industries, LP; three lakes drive; northfield IL 60093 -275
• Manufacturer Contact: vamshi pinnamshetty ; three lakes drive; northfield, IL 60093--275
• MDR Report Key: 50713384
• Report Number: 1417592-2026-35642
• Device Sequence Number: 10599148
• Product Code: OJH
• UDI-Device Identifier: 40195327449101
• UDI-Public: 40195327449101
• Combination Product (Y/N): N
• Initial Reporter State: OR
• Initial Reporter Country: US
• 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): 09/05/2026

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: DYNJ58506G
• Device Lot Number: 23GMF936
• Was Device Available for Evaluation?: No
• 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: 10/05/2023
• Initial Report FDA Received Date: 09/10/2026
• Was Device Evaluated by Manufacturer? (Y/N): No
• 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