MAUDE Adverse Event Report: ULRICH GMBH & CO. KG NOEO3; OCCIPITAL PLATE, MIDLINE, 47MM, FOR ROD Ø 4.0MM

Model Number	CS 3913-08
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	03/06/2020
Type of Reportable Event	Serious Injury
Event or Problem Description
A revision was done 6 march as a result of screws backing out.During the revision they discovered that a tulip head on the oc plate had broken off.Report 3 of 5.

• Brand Name: NOEO3
• Common Device Name: OCCIPITAL PLATE, MIDLINE, 47MM, FOR ROD Ø 4.0MM
• Manufacturer (Section D): ULRICH GMBH & CO. KG; buchbrunnenweg 12; ulm, 89081 ; GM 89081
• MDR Report Key: 9897259
• Report Number: 3005823819-2020-00008
• Device Sequence Number: 2828007
• Product Code: KWP
• UDI-Device Identifier: 04052536161485
• UDI-Public: 4052536161485
• Combination Product (Y/N): N
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2020
• Device Explanted Year: 2020
• Reporter Type: Importer
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 03/24/2020
• Report Date (Section F): 03/24/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: No Information
• Device Model Number: CS 3913-08
• Device Catalogue Number: CS 3913-08
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 03/06/2020
• Event Location: Hospital
• Date Report to Manufacturer: 03/24/2020
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 03/30/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Age: 69 YR