MAUDE Adverse Event Report: MEDLINE INDUSTRIES INC.; GAUZE IN LAPAROSCOPY PACK

Catalog Number	DYNJ60867
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	07/18/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
It was reported that during an unidentified procedure the gauze unraveled while inside of a patient's abdomen.The gauze was reportedly removed with no harm to the patient.Despite multiple good-faith attempts, the reporting facility was unable or unwilling to provide additional patient, product, or procedural information to the manufacturer.The use of the gauze during the unidentified procedure is unknown.No impact or adverse effect to the patient or to the unidentified procedure was originally reported to the manufacturer.No sample was returned to the manufacturer for evaluation.A root cause for the reported incident could not be determined.Due to the reported incident, and in an abundance of caution, this medwatch is being filed.If additional relevant information becomes available a supplemental medwatch will be filed.
Event or Problem Description
It was reported that the gauze unraveled while inside of a patient.

• Common Device Name: GAUZE IN LAPAROSCOPY PACK
• Manufacturer (Section D): MEDLINE INDUSTRIES INC.; three lakes drive; northfield IL 60093
• MDR Report Key: 8930857
• Report Number: 1423395-2019-00030
• Device Sequence Number: 2521178
• Product Code: FDE
• UDI-Device Identifier: 10193489663099
• UDI-Public: 10193489663099
• Combination Product (Y/N): N
• Initial Reporter State: CT
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: user facility
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 08/26/2019

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 Catalogue Number: DYNJ60867
• Device Lot Number: 19EBU517
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 08/06/2019
• Initial Report FDA Received Date: 08/26/2019
• 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: Required Intervention