Model Number CRK-17-50-2 |
Device Problem
Peeled/Delaminated (1454)
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Patient Problem
No Consequences Or Impact To Patient (2199)
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Event Date 04/05/2019 |
Event Type
malfunction
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Manufacturer Narrative
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The product involved in the report has been returned and is being processed for evaluation.The device history record for the reported lot number, m18127d215, in this complaint was reviewed and the material was produced according to the manufacturing procedures and met the quality requirements.All information reasonably known as of 26-apr-2019 has been included in this health authority report.Should additional information be obtained, a follow-up health authority report will be provided.Avanos medical, inc.Has no independent knowledge of the event reported but is relaying the information that was provided by the user facility where the incident occurred.This product incident is documented in the avanos medical, inc.Complaint database and identified as complaint (b)(4).
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Event Description
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Avanos medical, inc.Received a single report that referenced two different incidences, which were associated with same unit, involving two different events.This is the first of two reports.Refer to 8030647-2019-00046 for the second event.It was reported that during a knee procedure, depth markers were removed from three introducers placed in the knee.During first ablation at anterior femoral site, machine kept signaling high impedance and the clinicians were unable to complete the procedure.The two other procedure sites were done without incident.The clinicians returned to the first site and attempted the ablation once again.The pain management generator continued to indicate warning message of high impedance.The introducer was pulled back slightly and ablation was able to be completed.When introducer was removed, it was noticed that the polyimide coating stayed in the patient.The physician was able to remove it.
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Manufacturer Narrative
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One sample device was received.The device was evaluated.The sample was received with a 19mm segment of the polyimide tubing detached from the introducer.The segments were examined under magnification.Both exhibited jagged ends, with peeling on the outer surface.The failure was confirmed.The investigation concluded this appears to be isolated and use error is a potential root cause.All information reasonably known as of 09-jul-2019 has been included in this health authority report.Should additional information be obtained, a follow-up health authority report will be provided.The information provided by avanos medical, inc.Represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to avanos medical, inc.Avanos medical, inc.Has no independent knowledge of the event reported but is relaying the information that was provided by the user facility where the incident occurred.This product incident is documented in the avanos medical, inc.Complaint database and identified as complaint (b)(4).This information is submitted pursuant to 21cfr803, in compliance with the medical device reporting requirement and should not be considered to be an admission that an avanos medical, inc.Product is defective or caused serious injury.
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Search Alerts/Recalls
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