MAUDE Adverse Event Report: ETHICON INC. SILK BLK 18IN 5-0 S/A P-3 PRM MP; SUTURE, NONABSORBABLE, SILK

Model Number	640G
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	12/03/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).Attempts are being made to retrieve the device.To date the device has not been returned.If the device or further details are received at a later date a supplemental medwatch will be sent.
Event or Problem Description
It was reported that the patient underwent an unknown dental and oral surgery on 12/3/2019 and suture was used.The suture was broken easily during use.There were no adverse consequences to the patient.
Additional Manufacturer Narrative
(b)(4).Date sent to the fda: 02/04/2020.A manufacturing record evaluation was performed for the finished device lot mgq570, and no non-conformances were identified.Additional h3 investigation summary: an unopened sample of product code 640g, lot mgq570 was received for analysis.The complaint sample was not returned for evaluation.During the visual inspection of the sample, no defects were found on the package.The sample was opened, and the swage and attachment area were noted to be as expected.The suture was dispensed without problem and examined along of the strand and no defects, damaged or suture breakage were observed.A functional test was performed and the tensile strength force was above the minimum requirement.The manufacturing records were reviewed, and the manufacturing/packaging criteria were met prior to the release of this batch.Per the condition of the representative sample, no performance - breakage suture was found and the tested sample met the finished goods requirements.

• Brand Name: SILK BLK 18IN 5-0 S/A P-3 PRM MP
• Common Device Name: SUTURE, NONABSORBABLE, SILK
• Manufacturer (Section D): ETHICON INC.; p.o. box 151, route 22 west; somerville NJ 08876
• MDR Report Key: 9520765
• Report Number: 2210968-2019-91301
• Device Sequence Number: 546615
• Product Code: GAP
• UDI-Device Identifier: 10705031007369
• UDI-Public: 10705031007369
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K946173
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 12/05/2019

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: 640G
• Device Catalogue Number: 640G
• Device Lot Number: MGQ570
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 01/13/2020
• Initial Date Received by Manufacturer: 12/05/2019
• Supplement Date Received by Manufacturer: 01/13/2020
• Initial Report FDA Received Date: 12/26/2019
• Supplement Report FDA Received Date: 02/04/2020
• Patient Sequence Number: 1