MAUDE Adverse Event Report: COVIDIEN MFG DC BOULDER EDGE; ELECTROSURGICAL, CUTTING & COAGULATION & ACCESSORIES

Model Number	E1450-6
Medical Device Problem Code	Fire (1245)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
According to the reporter, during a thoracic procedure, they used the diathermy pencil and it was set to 50 with the medium tip and rubber shod to touch the forceps with it.They then noticed that the diathermy pencil has a flame on its tip and it was dropped on the floor.They stepped on the diathermy pencil tip that was on the floor and they used a new diathermy pencil with new medium tip and rubber shod and the setting was changed down to 20 to complete the case.There was no patient harm.
Additional Manufacturer Narrative
Evaluation summary: one device was received for evaluation.The returned electrode did not meet specification as received.Visual inspection found deformation and damage on the rubber shod and a small amount of charring on the electrode tip.The reported condition could not be confirmed, but the electrode showed damage consistent with heat damage.Inspection noted that the electrode tip was charred, and the coating was beginning to wear off.The rubber shod showed signs similar to thermal damage.The device was correctly assembled.Activating the device can result in arcing if other conductive objects are nearby, particularly at a higher power setting.Combustion can occur under these circumstances particularly when an enriched oxygen or nitrous oxide environment is present.The investigation identified the probable root cause of the reported event to be the user activating the device in such that the device arced.The instructions for use (ifu) states, both oxygen and nitrous oxide support combustion.Watch for enriched oxygen and nitrous oxide atmospheres near the surgical site, especially during head and neck surgery.Enriched oxygen atmospheres may result in fires and burns to patients or surgical personnel.Do not exceed the maximum power limits as stated in the ifu.Exceeding these power limits may result in patient injury or product damage.If the electrode is damaged, discard it.Always use the lowest power setting to achieve the desired surgical effect.The maximum power settings are detailed in the instructions for use.Some surgeons may elect to buzz the hemostats during a surgical procedure.This practice is not recommended and the hazards of such a practice probably cannot be eliminated.To minimize the risk, when using coated electrodes, place the edge of the electrode against the hemostat or metal instrument to assure a good electrical pathway.Do not activate the generator until the accessory makes contact with the instrument.Additional measures to minimize the risk of performing this technique are listed in the electrosurgical generator users manuals.If information is provided in the future, a supplemental report will be issued.
Additional Manufacturer Narrative
New information for follow up (b)(4) was notified to manufacturer on 2018-11-12.If information is provided in the future, a supplemental report will be issued.
Additional Manufacturer Narrative
Evaluation summary: one device was received for evaluation.The returned electrode did not meet specification as received.Visual inspection found deformation and damage on the rubber shod and a small amount of charring on the electrode tip.The reported condition could not be confirmed, but the electrode showed damage consistent with heat damage.Inspection noted that the electrode tip was charred, and the coating was beginning to wear off.The rubber shod showed signs similar to thermal damage.The device was correctly assembled.Activating the device can result in arcing if other conductive objects are nearby, particularly at a higher power setting.Combustion can occur under these circumstances particularly when an enriched oxygen or nitrous oxide environment is present.The investigation identified the probable root cause of the reported event to be the user activating the device in such that the device arced.The instructions for use (ifu) states, both oxygen and nitrous oxide support combustion.Watch for enriched oxygen and nitrous oxide atmospheres near the surgical site, especially during head and neck surgery.Enriched oxygen atmospheres may result in fires and burns to patients or surgical personnel.Do not exceed the maximum power limits as stated in the ifu.Exceeding these power limits may result in patient injury or product damage.If the electrode is damaged, discard it.Always use the lowest power setting to achieve the desired surgical effect.The maximum power settings are detailed in the instructions for use.Some surgeons may elect to buzz the hemostats during a surgical procedure.This practice is not recommended and the hazards of such a practice probably cannot be eliminated.To minimize the risk, when using coated electrodes, place the edge of the electrode against the hemostat or metal instrument to assure a good electrical pathway.Do not activate the generator until the accessory makes contact with the instrument.Additional measures to minimize the risk of performing this technique are listed in the electrosurgical generator users manuals.If information is provided in the future, a supplemental report will be issued.

• Brand Name: EDGE
• Common Device Name: ELECTROSURGICAL, CUTTING & COAGULATION & ACCESSORIES
• Manufacturer (Section D): COVIDIEN MFG DC BOULDER; 5920 longbow dr; boulder CO 80301 3299
• MDR Report Key: 7969006
• Report Number: 1717344-2018-01341
• Device Sequence Number: 1571952
• Product Code: GEI
• UDI-Device Identifier: 10884521713130
• UDI-Public: 10884521713130
• Combination Product (Y/N): N
• Initial Reporter Country: UK
• PMA/510(K) Number: K955836
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: foreign,user facility
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup,Followup,Followup
• Report Date (Section B): 12/12/2018

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: Health Professional
• Device Expiration Date: 09/02/2022
• Device Model Number: E1450-6
• Device Catalogue Number: E1450-6
• Device Lot Number: 72400115X
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 09/21/2018
• Initial Date Received by Manufacturer: 09/21/2018
• Supplement Date Received by Manufacturer: 11/12/2018; 11/12/2018; 11/12/2018
• Initial Report FDA Received Date: 10/16/2018
• Supplement Report FDA Received Date: 12/18/2019; 12/06/2018; 12/12/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1