MAUDE Adverse Event Report: INTUITIVE SURGICAL,INC. 8 MM LONG TIP FORCEPS; ENDOSCOPIC INSTRUMENT

Model Number	470048-08
Medical Device Problem Codes	Break (1069); Detachment Of Device Component (1104)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	11/14/2017
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Intuitive surgical, inc.(isi) received the instrument involved with this complaint and completed the device evaluation.Failure analysis confirmed the customer reported failure.For clarification, the instrument was found to have a broken pitch cable at the distal clevis hub.Motion was no longer intuitive at the wrist.The broken cable segment that contains the crimp was missing in the clevis.Missing crimp was approximately 0.046 x 0.032.The clevis did not exhibit any damage or wear marks.Isi has conducted a device history record (dhr) review for this device and did not find any non-conformances that were related to this reported event.The customer reported complaint does not itself constitute an mdr reportable event; however, the broken pitch cable found during failure analysis suggests that if the malfunction were to recur it could cause or contribute to an adverse event.
Event or Problem Description
It was reported that during a da vinci assisted procedure, a broken cable was noted on the long tip forceps instrument.There was no report of fragment(s) falling inside the patient, patient harm, adverse outcome or injury.

• Brand Name: 8 MM LONG TIP FORCEPS
• Common Device Name: ENDOSCOPIC INSTRUMENT
• Manufacturer (Section D): INTUITIVE SURGICAL,INC.; sunnyvale CA
• MDR Report Key: 7207797
• Report Number: 2955842-2018-00042
• Device Sequence Number: 13746487
• Product Code: NAY
• UDI-Device Identifier: 00886874112243
• UDI-Public: (01)00886874112243(10)N10171026
• Combination Product (Y/N): N
• Initial Reporter State: WI
• Initial Reporter Country: US
• PMA/510(K) Number: K131861
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: other
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 12/28/2017

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: Health Professional
• Device Model Number: 470048-08
• Device Lot Number: N10171026 0022
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 12/21/2017
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 12/28/2017
• Initial Report FDA Received Date: 01/19/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1