MAUDE Adverse Event Report: OLYMPUS MEDICAL SYSTEMS CORP. THUNDERBEAT 5 MM, 20 CM, INLINE GRIP; ULTRASONIC SURGICAL DEVICE

Model Number	TB-0520IC
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	03/13/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The device was returned to olympus for evaluation.A visual inspection was performed on the returned device and found evidence of use as there was some tissue build up on the jaw.The ptfe pad (teflon pad) was inspected and found to be separated from the jaw exposing metal.There was also evidence of charred marks on the teflon pad.The distal end of the device was inspected under a microscope and found no visual indication of damage to the probe unit.This type of teflon pad damage is most likely related to the operator's technique.The instruction manual contains several warning statements in an effort to prevent damage to the teflon pad."do not to activate output in seal and cut mode while the grasping section is closed without contacting tissue or vessel.Do not activate output while applying the probe tip to the tissue with a strong force.Do not activate output while grasping thick and hard tissues.Otherwise, various forms of damage in the probe tip and/or the tissue pad such as premature wear, breakage, deformation, exposure of metal, and/or falling inside the body cavity, and/or partial separating may occur.".
Event or Problem Description
Olympus was informed that a scheduled therapeutic colonoscopy procedure was never performed because the hand-piece was found to have the teflon pad hanging off.The hand-piece was inspected prior to use and that is when the damage was noticed.The device was never used on the patient.The intended procedure was completed using a similar device.There was no patient injury.

• Brand Name: THUNDERBEAT 5 MM, 20 CM, INLINE GRIP
• Common Device Name: ULTRASONIC SURGICAL DEVICE
• Manufacturer (Section D): OLYMPUS MEDICAL SYSTEMS CORP.; 2951 ishikawa-cho; hachioji-shi, tokyo-to 192-8 507; JA 192-8507
• MDR Report Key: 8600307
• Report Number: 2951238-2019-00831
• Device Sequence Number: 19406736
• Product Code: GEI
• UDI-Device Identifier: 04953170308710
• UDI-Public: 04953170308710
• Combination Product (Y/N): N
• Initial Reporter State: IL
• Initial Reporter Country: US
• PMA/510(K) Number: K132703
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Nurse
• Type of Report: Initial
• Report Date (Section B): 05/10/2019

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: TB-0520IC
• Device Lot Number: 81K26
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 04/03/2019
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/16/2019
• Initial Report FDA Received Date: 05/10/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1