MAUDE Adverse Event Report: STRYKER ENDOSCOPY-SAN JOSE RF 2 PROBES, MICRO-CLAW; ELECTROSURGICAL, CUTTING & COAGULATION & ACCESSORIES

Model Number	0279250101
Medical Device Problem Code	Fracture (1260)
Health Effect - Clinical Codes	No Consequences Or Impact To Patient (2199); Device Embedded In Tissue or Plaque (3165)
Date of Event	03/11/2020
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Additional information will be provided once the investigation has been completed.The device manufacturer date is not known at this time.However, should it become available it will be provided in future reports.
Event or Problem Description
It was reported that the device broke and the pieces remain in the patient.
Event or Problem Description
It was reported that the device broke and the pieces remain in the patient.
Additional Manufacturer Narrative
The product was returned for investigation and the reported failure mode was confirmed.The failure mode will be monitored for future reoccurrence.Alleged failure: the tip white ceramic insulation was fractured.The failure(s) identified in the investigation is consistent with the complaint record.The probable root cause/s could be excessive force used when inserting removing the probe, a probe inserted into an obstructed passageway or any forceful impact to the tip of the probe with rigid objects.The probe used as a tool for a mechanical displacement of tissue or bone, or to pry or scrub.

• Brand Name: RF 2 PROBES, MICRO-CLAW
• Common Device Name: ELECTROSURGICAL, CUTTING & COAGULATION & ACCESSORIES
• Manufacturer (Section D): STRYKER ENDOSCOPY-SAN JOSE; 5900 optical court; san jose CA 95138
• MDR Report Key: 9903205
• Report Number: 0002936485-2020-00152
• Device Sequence Number: 654302
• Product Code: GEI
• UDI-Device Identifier: 07613327056877
• UDI-Public: 07613327056877
• Combination Product (Y/N): N
• PMA/510(K) Number: K071859
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Nurse
• Type of Report: Initial,Followup
• Report Date (Section B): 05/28/2020

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?: Yes
• Operator of Device: Health Professional
• Device Model Number: 0279250101
• Device Catalogue Number: 0279250101
• Device Lot Number: 19018AE2
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 03/27/2020
• Initial Date Received by Manufacturer: 03/11/2020
• Supplement Date Received by Manufacturer: 03/11/2020
• Initial Report FDA Received Date: 03/31/2020
• Supplement Report FDA Received Date: 05/28/2020
• 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: Other