MAUDE Adverse Event Report: DEVICOR MEDICAL PRODUCTS INC. MAMMTOME REVOLVE ULTRASOUND PROBE; BIOPSY INSTRUMENT

Model Number	MHUS08
Medical Device Problem Code	Failure to Obtain Sample (2533)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	03/06/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Mhus08 probes are sterile, single use devices, indicated to obtain tissue samples from the breast or axillary lymph nodes for diagnostic analysis of breast abnormalities.The device has not yet been received by devicor medical products, inc.For evaluation.Therefore we are unable to determine a root cause for the reported incident.If the tissue is found within the vacuum line rather than in the sample management system, a misdiagnosis is possible due to lost tissue.Following consultation with our medical director, due to the potential to cause or contribute to death or serious injury as a result of potential missed or lost tissue samples, pursuant to 21 cfr §803, this failure mode was determined to be a reportable malfunction.
Event or Problem Description
Devicor medical products inc.Received a report from our affiliate, devicor medical (b)(4), stating, during a breast biopsy procedure, after 3-4 samples were taken, a 603 error message occurred and one of the sample is in the vacuum tubing line.This has been documented in our system as record # (b)(4).

• Brand Name: MAMMTOME REVOLVE ULTRASOUND PROBE
• Common Device Name: BIOPSY INSTRUMENT
• Manufacturer (Section D): DEVICOR MEDICAL PRODUCTS INC.; 300 e. business way; fifth floor; cincinnati OH 45241
• MDR Report Key: 8518465
• Report Number: 3008492462-2019-00018
• Device Sequence Number: 19239762
• Product Code: KNW
• UDI-Device Identifier: 00841911100812
• UDI-Public: (01)00841911100812(17)210924(10)F11838465D
• Combination Product (Y/N): N
• PMA/510(K) Number: K152989
• 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
• Report Date (Section B): 04/16/2019

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: 09/24/2021
• Device Model Number: MHUS08
• Device Catalogue Number: MHUS08
• Device Lot Number: F11838465D
• Was Device Available for Evaluation?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/27/2019
• Initial Report FDA Received Date: 04/16/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1