MAUDE Adverse Event Report: COOK INC OPTILITE SINGLE-USE HOLMIUM LASER FIBER; GEX LASER INSTRUMENT, SURGICAL

Catalog Number	HLF-S273-SMA
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	11/20/2015
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
This mdr is being filed after the associated complaint was reviewed under remediation protocol (b)(4), complaint/mdr retrospective review and remediation and reassessed as reportable.Additional complaint investigation and record remediation was not performed.Blank fields on this form that have not been previously submitted indicate the information is unknown or unavailable.
Event or Problem Description
The complainant reported that the patient underwent a right ureteroscopy and laser lithotripsy.The laser settings were 0.8 j (joules), 8 pulse/seconds with a total energy of 0.88kj (kilojoules).The optilite single-use holmium laser fiber broke, and once it broke, the physician stopped firing the laser and removed the fiber immediately.Another fiber was used to complete the procedure, and the product problem did not result in any reported serious injuries to the patient.

• Brand Name: OPTILITE SINGLE-USE HOLMIUM LASER FIBER
• Common Device Name: GEX LASER INSTRUMENT, SURGICAL
• Manufacturer (Section D): COOK INC; 750 daniels way; bloomington IN 47404
• MDR Report Key: 7743011
• Report Number: 1820334-2018-02378
• Device Sequence Number: 1678879
• Product Code: GEX
• UDI-Device Identifier: 00827002485266
• UDI-Public: (01)00827002485266(17)181006(10)6210176
• Combination Product (Y/N): N
• Initial Reporter State: PA
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,user f
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 08/02/2018

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: No Information
• Device Expiration Date: 10/06/2018
• Device Catalogue Number: HLF-S273-SMA
• Device Lot Number: 6210176
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 07/30/2018
• Initial Report FDA Received Date: 08/02/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Weight: 55