MAUDE Adverse Event Report: PHILIPS ULTRASOUND, INC TRANSDUCER S7-3T; 21781A TEE PROBE ASSEMBLY

Model Number 989605406772

Device Problem Crack (1135)

Patient Problem No Known Impact Or Consequence To Patient (2692)

Event Type  malfunction  

Manufacturer Narrative

Evaluation of the transducer will be included in a follow up report upon its return and investigation completion.

Event Description

A customer reported that while performing a procedure with an s7-3t model transducer, a portion of the probe¿s tip cracked and began to detach from the device.The transducer was promptly removed from the patient¿s throat with no part of the probe remaining in the patient.The site¿s philips field service engineer confirmed there were no injuries associated with this event.The suspect transducer has been removed from service and will be returned for evaluation.

Manufacturer Narrative

A thorough evaluation of the s7-3t model transducer identified extensive damage to the device.Examination of the transducer noted a missing sheath, a bite mark, a worn and peeling shaft, deep scratches, a dirty handle, dried fluid in the connector, chipped connector housing paint, a discolored connector strain relief, and a damaged control handle.Performance testing revealed a failed icon check and a loss of steering from the top knob.Further evaluation revealed the detached sheath had been exposed to a disinfectant only approved for use on the connector and cable.Inappropriate cleansing or disinfection of this device would have contributed to the material failure and are indicative of improper handling and maintenance.

• Brand Name: TRANSDUCER S7-3T
• Type of Device: 21781A TEE PROBE ASSEMBLY
• Manufacturer (Section D): PHILIPS ULTRASOUND, INC; 22100 bothell everett highway; bothell WA 98021
• Manufacturer (Section G): PHILIPS MEDICAL SYSTEMS; 3000 minuteman road; andover MA 01810
• Manufacturer Contact: paul corrigan ; 22100 bothell everett highway; bothell, WA 98021 ; 4254877000
• MDR Report Key: 6765648
• MDR Text Key: 81905655
• Report Number: 3019216-2017-00027
• Device Sequence Number: 1
• Product Code: ITX
• UDI-Device Identifier: 00884838061439
• UDI-Public: (01)00884838061439
• Combination Product (y/n): N
• Reporter Country Code: CH
• PMA/PMN Number: K132304
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: user facility
• Reporter Occupation: Biomedical Engineer
• Remedial Action: Replace
• Type of Report: Initial,Followup
• Report Date: 07/24/2017

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
• Device Operator: Health Professional
• Device Model Number: 989605406772
• Device Lot Number: B1CM64
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 10/28/2017
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Initial Date Manufacturer Received: 07/24/2017
• Initial Date FDA Received: 08/03/2017
• Supplement Dates Manufacturer Received: 07/24/2017
• Supplement Dates FDA Received: 01/23/2018
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 08/22/2016
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Reuse
• Patient Sequence Number: 1