MAUDE Adverse Event Report: NEVRO CORP. NEVRO; NEVRO SENZA

Model Number	EPMD1040
Medical Device Problem Code	Detachment of Device or Device Component (2907)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	03/05/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Nevro is awaiting the return of the insertion needle.The manufacturing records were reviewed and no non-conformities were found.
Event or Problem Description
It was reported to nevro that the insertion needle detached from the hub during the trial procedure.The physician was able to remove the insertion needle without incident and there were no injuries to the patient.The procedure was completed with no further reports of complications and the patient had a successful trial.
Additional Manufacturer Narrative
Follow-up indicated that the device was discarded and not available for return.This issue has been addressed with the manufacturer and corrective action has been implemented.Review of the severity and occurrence rate for this type of event shows that the overall risk is within acceptable limits.

• Brand Name: NEVRO
• Common Device Name: NEVRO SENZA
• Manufacturer (Section D): NEVRO CORP.; 1800 bridge parkway; redwood city CA 94065
• MDR Report Key: 8480914
• Report Number: 3008514029-2019-00117
• Device Sequence Number: 13718805
• Product Code: LGW
• UDI-Device Identifier: 00818788020338
• UDI-Public: 00818788020338
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: P130022
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 05/21/2019

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?: No
• Operator of Device: Health Professional
• Device Expiration Date: 01/21/2023
• Device Model Number: EPMD1040
• Device Lot Number: 12148539
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/05/2019
• Supplement Date Received by Manufacturer: 03/05/2019
• Initial Report FDA Received Date: 04/03/2019
• Supplement Report FDA Received Date: 05/21/2019
• 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
• Patient Age: 74 YR