MAUDE Adverse Event Report: K2M, INC. PYRENEES CERVICAL PLATE SYSTEM; DRIVER, SCREW INSERTER

Catalog Number	201-90118
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Information (3190)
Date of Event	05/23/2016
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
A comprehensive investigation was immediately initiated on receipt of the complaint.The product has not yet been returned to manufacturer for evaluation, and a thorough investigation cannot be completed at this time.If further information becomes available manufacturer will file a follow-up report at that time.Received notification on 06/06/2016 from fda that user facility reported this case under (b)(4).
Event or Problem Description
It was reported to k2m, inc on 6/2/2016 that on (b)(6) 2016 a driver tip sheared off in the screw head intra-op and was left in the screw.
Additional Manufacturer Narrative
A comprehensive investigation was immediately initiated on receipt of the complaint.The product was not returned to manufacturer for evaluation, and a thorough investigation could not be completed as no lot number has been identified/confirmed in this case.Since the driver was retained by the hospital no physical, material, chemical evaluation could be performed, and the exact cause of the reported issue could not be ascertained.A general review of the manufacturing and inspection records did not reveal any contributing information/trends.Received notification on 06/06/2016 from fda that user facility reported this case under uf/importer report #: (b)(4).Not returned.
Event or Problem Description
It was reported to k2m, inc on 6/2/2016 that on (b)(6) 2016 a driver tip sheared off in the screw head intra-op and was left in the screw.

• Brand Name: PYRENEES CERVICAL PLATE SYSTEM
• Common Device Name: DRIVER, SCREW INSERTER
• Manufacturer (Section D): K2M, INC.; 600 hope parkway se; leesburg VA 20175
• MDR Report Key: 5725493
• Report Number: 3004774118-2016-00045
• Device Sequence Number: 19005975
• Product Code: HXX
• UDI-Device Identifier: 10888857030183
• UDI-Public: 10888857030183
• Combination Product (Y/N): N
• Initial Reporter State: VA
• 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
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 06/02/2016

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
• Operator of Device: Physician
• Device Catalogue Number: 201-90118
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: No
• Type of Report(Section G): FDA Requested
• Initial Date Received by Manufacturer: 06/02/2016
• Supplement Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 06/15/2016
• Supplement Report FDA Received Date: 07/13/2016
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 61 YR