MAUDE Adverse Event Report: DAVIS & GECK CARIBE LTD DFS; STAPLE, IMPLANTABLE

Model Number	070614
Medical Device Problem Codes	Break (1069); Failure to Form Staple (2579)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	08/22/2019
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, during a inguinal hernia repair open procedure, when attaching hernia mesh, the second firing staple needed to be removed as the stapler was not firing correctly and the reload was coming out with the staples.The case was finished with suture.There was no patient injury.

• Brand Name: DFS
• Common Device Name: STAPLE, IMPLANTABLE
• Manufacturer (Section D): DAVIS & GECK CARIBE LTD; zona franca de san isidro; santo domingo 0101 ; DO 0101
• MDR Report Key: 9081537
• Report Number: 9612501-2019-01765
• Device Sequence Number: 14153749
• Product Code: GDW
• UDI-Device Identifier: 10884521080744
• UDI-Public: 10884521080744
• Combination Product (Y/N): N
• Initial Reporter Country: AS
• PMA/510(K) Number: K780695
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 09/18/2019

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 Expiration Date: 05/31/2023
• Device Model Number: 070614
• Device Catalogue Number: 070614
• Device Lot Number: J8E1843X
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 08/23/2019
• Initial Report FDA Received Date: 09/18/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1