MAUDE Adverse Event Report: APPLIED MEDICAL RESOURCES G-6155, 61MM INSERT F/F 15/BX; DXC

Model Number	G-6155
Medical Device Problem Code	Detachment Of Device Component (1104)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	11/14/2017
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The incident device is anticipated to return.A follow-up report will be provided upon completion of the investigation.
Event or Problem Description
Procedure performed: "unknown" incident description: a medical staff tried to attach the insert to a clamp.Then the medical staff found that the part of fibra was peeled off from the rubber base.Another insert was used for the procedure and the procedure was completed with no problem.It didn't affect the patient." type of intervention: "another insert was used for the procedure and the procedure was completed with no problem." patient status: "it didn't affect the patient.".
Additional Manufacturer Narrative
Investigation summary: the event unit was returned to applied medical for evaluation.Upon visual inspection engineering confirmed that the fibra layer had partially separated from the insert pad.Based on the condition of the returned unit, the exact root cause of the event could not be determined.The probability and criticality of harm resulting from this failure mode have been evaluated and were found to be at an acceptable level.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.

• Brand Name: G-6155, 61MM INSERT F/F 15/BX
• Common Device Name: DXC
• Manufacturer (Section D): APPLIED MEDICAL RESOURCES; 22872 avenida empresa; rancho santa margarita CA 92688
• MDR Report Key: 7068013
• Report Number: 2027111-2017-02134
• Device Sequence Number: 13689078
• Product Code: DXC
• UDI-Device Identifier: 00607915111274
• UDI-Public: (01)00607915111274(17)201121(30)01(10)1260098
• Combination Product (Y/N): N
• PMA/510(K) Number: K883790
• 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,Followup
• Report Date (Section B): 01/19/2018

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: 11/21/2020
• Device Model Number: G-6155
• Device Catalogue Number: 100063301
• Device Lot Number: 1260098
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 12/05/2017
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 11/24/2017
• Supplement Date Received by Manufacturer: 11/24/2017
• Initial Report FDA Received Date: 11/29/2017
• Supplement Report FDA Received Date: 01/19/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• If action reported to FDA under 21 USC 360i(g), list FDA-assigned Recall Number or include a statement: N/A
• Patient Sequence Number: 1