MAUDE Adverse Event Report: APPLIED MEDICAL RESOURCES CFR03, 5X100 KII OPT ADVFIX 6/BX; GCJ

Model Number	3
Medical Device Problem Code	Material Fragmentation (1261)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	06/06/2014
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The event product was returned to applied medical for evaluation with a rubber fragment.Upon inspection, engineering noted the dislodgement of the shield, an internal component of seal.Engineering also observed fragmentation of an internal rubber component of the seal.Functional leak testing was performed on the seal, and the unit did not meet specifications.The likely root cause of the damage to the seal is an instrument.Applied medical will continue to monitor its vigilance system for trends and take appropriate actions, as necessary, to ensure the performance and safety of its products.This report is being filed as a result of a re-review of applied medical complaints received between june 1, 2014 and may 31, 2016.This retrospective review was associated with a quality management system (qms) compliance action plan developed and presented to fda to address an april 10, 2015 warning letter.Applied medical has revised its mdr reporting criteria to be more conservative and has improved complaint handling and mdr reporting processes.The reviews ensured that recent reportable events were appropriately identified and reported to the designated regulatory authority(ies).This report, which represents the initial and final reports combined, is being submitted based on the findings of that retrospective review.In accordance with 21 cfr 803.56, if additional information is obtained which was not known or was not available when this report was submitted, then a supplemental report will be submitted to the fda.
Event or Problem Description
Procedure performed unknown- "this is the complaint from the market.(b)(4).Please refer to the complaint sheet for investigation.Physician found black debris dropped off from cannula during an operation and recovered the debris.Noticing insufflation leakage and replaced the event unit to a different unit and completed the procedure.There was no health damage to patient.(b)(4) olympus received the event unit and the black debris.On evaluating them, we confirmed septum breach and also confirmed the debris was a portion of the septum.The debris is approximately 4.7mm by 3.1mm.Please analyze this phenomenon and review the device history records of the event unit." patient status: patient was not injured.

• Brand Name: CFR03, 5X100 KII OPT ADVFIX 6/BX
• Common Device Name: GCJ
• Manufacturer (Section D): APPLIED MEDICAL RESOURCES; 22872 avenida empresa; rancho santa margarita CA 92688
• MDR Report Key: 6372809
• Report Number: 2027111-2017-01054
• Device Sequence Number: 442347
• Product Code: GCJ
• UDI-Device Identifier: 00607915119881
• UDI-Public: (01)00607915119881(17)170217(30)01(10)1215310
• Combination Product (Y/N): N
• PMA/510(K) Number: 3
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,distri
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 03/02/2017

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: Other
• Device Expiration Date: 02/17/2017
• Device Model Number: 3
• Device Catalogue Number: 3
• Device Lot Number: 1215310
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 06/27/2014
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 06/19/2014
• Initial Report FDA Received Date: 03/02/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1