MAUDE Adverse Event Report: AMERICAN CONTRACT SYSTEMS, INC. ACS; GENERAL SURGERY TRAY

Model Number	CDMH06E
Health Effect - Clinical Code	No Patient Involvement (2645)
Date of Event	01/31/2019
Type of Reportable Event	Malfunction
Event or Problem Description
A hair was found on the plastic blue basin in the anterior hip pack (cdmh06e) prior to the patient entering the operating room.The basin and supplies were thrown away and a new sterile field was set up.

• Brand Name: ACS
• Common Device Name: GENERAL SURGERY TRAY
• Manufacturer (Section D): AMERICAN CONTRACT SYSTEMS, INC.; 904 bethel circle; waunakee WI 53597
• MDR Report Key: 8300775
• Report Number: 8300775
• Device Sequence Number: 155094
• Product Code: LRP
• UDI-Device Identifier: 00191072029324
• UDI-Public: (01)00191072029324(17)191212(10)654181
• Combination Product (Y/N): N
• Initial Reporter State: VA
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: User Facility
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 01/31/2019
• Report Date (Section F): 01/31/2019

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 Model Number: CDMH06E
• Device Lot Number: 654181
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: Yes
• Event Location: Hospital
• Date Report to Manufacturer: 02/04/2019
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 02/04/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Weight: 52
• Date Report Sent to FDA: 01/31/2019