MAUDE Adverse Event Report: PAJUNK GMBH MEDIZINTECHNOLOGIE SPROTTE; ANAESTHESIA CONDUCTION CANNULA, SPINAL, SINGLE SHOT

Model Number	501151-29AB
Medical Device Problem Code	Failure To Adhere Or Bond (1031)
Health Effect - Clinical Codes	No Consequences Or Impact To Patient (2199); Foreign Body In Patient (2687)
Date of Event	02/06/2018
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Vent took place in (b)(6) and has been reported through (b)(4) distribution subsidiary (b)(4).Currently the data is poor and the device has not been returned/ analysed.As soon as further data will be available a follow up report will be sent in to the agency.
Event or Problem Description
(b)(4).Summarizing tentative translation of initial reporter´s narrative: upon removal of the spinal needle the hub came off the needle.
Event or Problem Description
Irn# (b)(4).Summarizing tentative translation of initial reporter´s narrative: upon removal of the spinal needle the hub came off the needle.
Additional Manufacturer Narrative
Event took place in (b)(6) and has been reported through (b)(4) distribution subsidiary pajunk medical produkte (b)(4).Based on risk management and clinical assessment this file is considered as closed.

• Brand Name: SPROTTE
• Common Device Name: ANAESTHESIA CONDUCTION CANNULA, SPINAL, SINGLE SHOT
• Manufacturer (Section D): PAJUNK GMBH MEDIZINTECHNOLOGIE; karl-hall-str. 1; tuttlinger str. 7; geisingen, baden-wuerttemberg 78187 ; GM 78187
• MDR Report Key: 7295479
• Report Number: 9611612-2018-00018
• Device Sequence Number: 11133760
• Product Code: BSP
• UDI-Device Identifier: 14048223000844
• UDI-Public: 14048223000844
• Combination Product (Y/N): N
• Initial Reporter Country: GM
• PMA/510(K) Number: K911202
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,distri
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 03/29/2018

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Operator of Device: Physician
• Device Expiration Date: 09/11/2022
• Device Model Number: 501151-29AB
• Device Catalogue Number: 501151-29AB
• Device Lot Number: 1220
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 02/14/2018
• Was the Report Sent to FDA?: No
• Initial Date Received by Manufacturer: 02/18/2018
• Supplement Date Received by Manufacturer: 02/18/2018
• Initial Report FDA Received Date: 02/26/2018
• Supplement Report FDA Received Date: 03/29/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other; Required Intervention