MAUDE Adverse Event Report: ETHICON INC. PROLENE SUT 24IN(60CM) 7-0 BLU; SUTURE, NONABSORBABLE, SYNTHETIC, POLYPROPYLENE

Model Number	8304H
Medical Device Problem Code	Material Separation (1562)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	01/14/2020
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).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 cabg procedure on (b)(6) 2020 and suture was used.During the procedure, the needle popped off of suture.The procedure was completed with similar device.There were no adverse patient consequences reported.
Additional Manufacturer Narrative
Additional information: d4, h4, h6.A manufacturing record evaluation was performed for the finished device batch and no non-conformances were identified.

• Brand Name: PROLENE SUT 24IN(60CM) 7-0 BLU
• Common Device Name: SUTURE, NONABSORBABLE, SYNTHETIC, POLYPROPYLENE
• Manufacturer (Section D): ETHICON INC.; p.o. box 151, route 22 west; somerville NJ 08876
• MDR Report Key: 9681408
• Report Number: 2210968-2020-01010
• Device Sequence Number: 19533005
• Product Code: GAW
• UDI-Device Identifier: 10705031014114
• UDI-Public: 10705031014114
• Combination Product (Y/N): N
• Initial Reporter State: OH
• Initial Reporter Country: US
• PMA/510(K) Number: K133356
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 01/15/2020

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: 04/30/2024
• Device Model Number: 8304H
• Device Catalogue Number: 8304H
• Device Lot Number: PEH452
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 01/15/2020
• Supplement Date Received by Manufacturer: 02/27/2020
• Initial Report FDA Received Date: 02/07/2020
• Supplement Report FDA Received Date: 03/05/2020
• Patient Sequence Number: 1