MAUDE Adverse Event Report: STRYKER ENDOSCOPY-SAN JOSE CHAMPION SLINGSHOT 45 RIGHT; ORTHOPEDIC MANUAL SURGICAL INSTRUMENT

Catalog Number	CAT02855
Health Effect - Clinical Code	Device Embedded In Tissue or Plaque (3165)
Date of Event	07/01/2019
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Additional information will be provided once the investigation has been completed.The device manufacturer date is not known at this time.However, should it become available it will be provided in future reports.
Event or Problem Description
It was reported that the tip broke and remained inside the patient.
Event or Problem Description
It was reported that the tip broke and remained inside the patient.
Additional Manufacturer Narrative
This complaint investigation was closed based on the device not received, therefore the reported failure mode was not confirmed.In the event that the device is received, the complaint will be reopened and the investigation will be updated with new results.Alleged failure: tip broke off.Probable root cause: design: instrument tip not designed for insertion into cannula.Improper raw material selection.Assembly design not strong enough to withstand insertion effort.Manufacturing.Incorrect raw materials used.Instrument not manufactured to specification.Instrument not assembled properly.Application.Excessive force.User attempts to insert into cannula which already supports access of other.Instruments to the joint space.User attempts to insert device without use of a cannula.The reported failure mode will be monitored for future reoccurrence.The device manufacturer date is not known.

• Brand Name: CHAMPION SLINGSHOT 45 RIGHT
• Common Device Name: ORTHOPEDIC MANUAL SURGICAL INSTRUMENT
• Manufacturer (Section D): STRYKER ENDOSCOPY-SAN JOSE; 5900 optical court; san jose CA 95138
• MDR Report Key: 8836742
• Report Number: 0002936485-2019-00312
• Device Sequence Number: 16790963
• Product Code: HWQ
• UDI-Device Identifier: 07613327123692
• UDI-Public: 07613327123692
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: EXEMPT
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 10/23/2019

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?: Yes
• Operator of Device: Health Professional
• Device Catalogue Number: CAT02855
• Device Lot Number: 003446
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 07/01/2019
• Supplement Date Received by Manufacturer: 07/01/2019
• Initial Report FDA Received Date: 07/29/2019
• Supplement Report FDA Received Date: 10/23/2019
• 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