MAUDE Adverse Event Report: STRYKER ENDOSCOPY-SAN JOSE PKG, 1188 C-MOUNT COUPLER; LAPAROSCOPE, GENERAL & PLASTIC SURGERY

Catalog Number	1188020122
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	07/25/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The device manufacture date is not known at this time.However, should it become available it will be provided in future reports.Additional information will be provided once the investigation has been completed.
Event or Problem Description
It was reported that the device had a dark image.A replacement was used to complete the procedure.
Additional Manufacturer Narrative
Alleged failure: poor image.The failure alleged in the complaint record was not confirmed/duplicated during the product investigation.Root cause: coupler conforms to specifications.During testing it was determined that the complaint reported was a camera head issue.The product was returned for investigation and the failure mode will be monitored for future reoccurrence.The device manufacturer date is not known.
Event or Problem Description
It was reported that the device had a dark image.A replacement was used to complete the procedure.

• Brand Name: PKG, 1188 C-MOUNT COUPLER
• Common Device Name: LAPAROSCOPE, GENERAL & PLASTIC SURGERY
• Manufacturer (Section D): STRYKER ENDOSCOPY-SAN JOSE; 5900 optical court; san jose CA 95138
• MDR Report Key: 9070250
• Report Number: 0002936485-2019-00391
• Device Sequence Number: 1878958
• Product Code: GCJ
• UDI-Device Identifier: 07613327063325
• UDI-Public: 07613327063325
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: K142603
• 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): 10/31/2019

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: 1188020122
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 08/21/2019
• Initial Date Received by Manufacturer: 08/21/2019
• Supplement Date Received by Manufacturer: 08/21/2019
• Initial Report FDA Received Date: 09/16/2019
• Supplement Report FDA Received Date: 10/31/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1