MAUDE Adverse Event Report: COVIDIEN MFG DC BOULDER SURGISTAT; ELECTROSURGICAL, CUTTING & COAGULATION & ACCESSORIES

Model Number	SURGII-8
Medical Device Problem Codes	Inaccurate Delivery (2339); Device Displays Incorrect Message (2591)
Health Effect - Clinical Code	No Patient Involvement (2645)
Date of Event	03/27/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
According to the reporter, the unit had an error code e6.The unit must be reset.Patient return electrode test failing at: increasing resistance alarm from 120 should trip before 150, did not trip before 164.There was no patient involved.
Additional Manufacturer Narrative
One device was received as a service request and a visual inspection and functional test were performed.The unit must be reset.Patient return electrode test failing at: increasing resistance alarm from 120 should trip before 150, did not trip before 164.The reported condition was confirmed.According to the technician, "issue confirmed.Needs updates to the digital nem for nem issue and configuration prom for e6 issue.Received with one sleeve cracked on the bipolar connector.Unit needs all updates per wi-tsu-006_3.U4 heat sink update, speaker update, analog nem to digital nem update, encoders, main pcb barrier, display configuration prom." the investigation identified the cause of the reported event to be wear and tear.The connector socket assembly was replaced to address the issue.The following upgrades were also performed: two encoder spacers, main pcb barrier, speaker with one 100 ohm resistor and 1in shrink tubing; u4 heat sink with nut and screw; nem with one digital nem pcb, nem configuration prom, nem mounting bracket, two nylon screws and two nylon nuts; ohm resistors, one screw, one nut, and one lock washer; display configuration prom rev.C.¿during the removal of the old nem pads were damaged on the main board so the main board was replaced.¿ the unit was subjected to full factory testing / calibration with qa-220_27.It passed all testing with no problems or issues found.Medtronic is submitting this report to comply with fda reporting regulations under 21 cfr parts 4 and 803.This report is based upon information obtained by medtronic, which the company may not have been able to fully investigate or verify prior to the date the report was required by the fda.Medtronic has made reasonable efforts to obtain more complete information and has provided as much relevant information as is available to the company as of the submission date of this report.This report does not constitute an admission or a conclusion by fda, medtronic, or its employees that the device, medtronic, or its employee caused or contributed to the event described in the report.In particular, this report does not constitute an admission by anyone that the product described in this report has any ¿defects¿ or has ¿malfunctioned¿.These words are included in the fda 3500a form and are fixed items for selection created by the fda to categorize the type of event solely for the purpose of regulatory reporting.Medtronic objects to the use of these words and others like them because of the lack of definition and the connotations implied by these terms.This statement should be included with any information or report disclosed to the public under the freedom of information act.Any required fields that are unpopulated are blank because the information is currently unknown or unavailable.A good faith effort will be made to obtain the applicable information relevant to the report.If information is provided in the future, a supplemental report will be issued.

• Brand Name: SURGISTAT
• Common Device Name: ELECTROSURGICAL, CUTTING & COAGULATION & ACCESSORIES
• Manufacturer (Section D): COVIDIEN MFG DC BOULDER; 5920 longbow dr; boulder CO 80301 3299
• MDR Report Key: 8592176
• Report Number: 1717344-2019-00609
• Device Sequence Number: 2011438
• Product Code: GEI
• UDI-Device Identifier: 10884521035928
• UDI-Public: 10884521035928
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K001955
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: consumer,user facility
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 10/16/2019

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: SURGII-8
• Device Catalogue Number: SURGII-8
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 04/05/2019
• Initial Date Received by Manufacturer: 04/17/2019
• Supplement Date Received by Manufacturer: 10/01/2019
• Initial Report FDA Received Date: 05/08/2019
• Supplement Report FDA Received Date: 10/16/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1