MAUDE Adverse Event Report: STRYKER INSTRUMENTS-KALAMAZOO SILVERGLIDE BIPOLAR PRECISION FORCEPS BAYONET, 24CM / 1.2MM TIP; ELECTROSURGICAL, CUTTING & COAGULATION & ACCESSORIES

Catalog Number	6720240012
Medical Device Problem Code	Detachment of Device or Device Component (2907)
Health Effect - Clinical Code	No Patient Involvement (2645)
Date of Event	11/20/2018
Type of Reportable Event	Malfunction
Event or Problem Description
The device insulation was found to be peeling off of the device, posing the risk of a small component being lost in a surgical site, during testing at the user facility.There was no patient involvement, no delay, no medical intervention, and no adverse consequences.
Additional Manufacturer Narrative
Follow-up report submitted to document device evaluation results.Device not received for evaluation.
Event or Problem Description
The device insulation was found to be peeling off of the device, posing the risk of a small component being lost in a surgical site, during testing at the user facility.There was no patient involvement, no delay, no medical intervention, and no adverse consequences.

• Brand Name: SILVERGLIDE BIPOLAR PRECISION FORCEPS BAYONET, 24CM / 1.2MM TIP
• Common Device Name: ELECTROSURGICAL, CUTTING & COAGULATION & ACCESSORIES
• Manufacturer (Section D): STRYKER INSTRUMENTS-KALAMAZOO; 4100 east milham avenue; kalamazoo MI 49001
• MDR Report Key: 8175148
• Report Number: 0001811755-2018-02794
• Device Sequence Number: 16503286
• Product Code: GEI
• UDI-Device Identifier: 04546540532336
• UDI-Public: 04546540532336
• Combination Product (Y/N): N
• Initial Reporter State: KS
• Initial Reporter Country: US
• PMA/510(K) Number: K992931
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: user facility
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 05/10/2019

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 Catalogue Number: 6720240012
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: Yes
• Initial Date Received by Manufacturer: 11/20/2018
• Supplement Date Received by Manufacturer: 05/09/2019
• Initial Report FDA Received Date: 12/18/2018
• Supplement Report FDA Received Date: 05/10/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1