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

Model Number	070614
Medical Device Problem Codes	Entrapment of Device (1212); Failure to Form Staple (2579)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	09/29/2019
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 an open hernia procedure, when firing, staples partially deployed but was stuck in the end of the stapler and was caught on tissue.Staples that were deployed did not form properly.Another stapler was used to complete the procedure.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: 9197886
• Report Number: 9612501-2019-02004
• Device Sequence Number: 19480317
• Product Code: GDW
• UDI-Device Identifier: 10884521080744
• UDI-Public: 10884521080744
• Combination Product (Y/N): N
• Initial Reporter Country: EG
• PMA/510(K) Number: K780695
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,distri
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 10/16/2019

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: 06/30/2023
• Device Model Number: 070614
• Device Catalogue Number: 070614
• Device Lot Number: J8F0291X
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 09/29/2019
• Initial Report FDA Received Date: 10/16/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 43 YR
• Patient Weight: 100