DOUBLEAIRHOSE L5M F/SYST SYNTHES 519.530

MAUDE Adverse Event Report

MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a company representative,foreig report with the FDA on 2017-10-11 for DOUBLEAIRHOSE L5M F/SYST SYNTHES 519.530 manufactured by Umkirch.

Event Text Entries

[90078330] (b)(4). Device manufacture date: the device manufacture date is unavailable. The manufacturing location is currently not available. (b)(6). As of this date, the device has not been returned for evaluation; therefore, the reported condition cannot be confirmed and/or duplicated. If information is obtained that was not available for the initial medwatch, a follow-up medwatch will be filed as appropriate.
Patient Sequence No: 1, Text Type: N, H10


[90078351] This is report 3 of 3 for the same event: it was reported from (b)(6) that during an unspecified surgical procedure, it was discovered that the battery handpiece device did not work while in use with a lid device. It was reported that the surgeon changed to another handpiece device; however, the hose had a leak. It was further reported that the handpiece device was changed again and the surgery was completed. There was a thirty minute delay to the surgical procedure. There was patient involvement reported. It was reported that there was no consequence to the patient. There were no reports of injuries, medical intervention or prolonged hospitalization. All available information has been disclosed. If additional information should become available, a supplemental medwatch report will be submitted accordingly.
Patient Sequence No: 1, Text Type: D, B5


[117020919] (b)(4). The manufacturer location was documented as unknown in the initial report. The location has been updated to (b)(6). Contact office name/address has been updated accordingly to reflect the corrected manufacturing facility. Device manufacture date: the device manufacture date was documented as unknown in the initial report. The device manufacture date has been updated as jun 7, 2001. Device evaluation: this device was returned for service; however, did not meet manufacturing specifications during pre-repair assessment. During repair, it was determined that the reported condition was confirmed. It was determined that the hose was leaking and the hose couplings were heavily worn and leaky. It was determined that the inner hose was broken from the coupling head. It was further determined that the device failed pretest for function check coupling and nipple for any leakage, perform pressure test for double air hose no leakage and perform pressure test for single air hose no leakage. The assignable root cause was determined to be due to wear from normal use and servicing. If additional information should become available, a supplemental medwatch report will be submitted accordingly.
Patient Sequence No: 1, Text Type: N, H10


MAUDE Entry Details

Report Number8030965-2017-15421
MDR Report Key6941458
Report SourceCOMPANY REPRESENTATIVE,FOREIG
Date Received2017-10-11
Date of Report2017-09-22
Date of Event2017-09-21
Date Mfgr Received2017-10-24
Device Manufacturer Date2001-06-07
Date Added to Maude2017-10-11
Event Key0
Report Source CodeManufacturer report
Manufacturer LinkY
Number of Patients in Event0
Adverse Event Flag3
Product Problem Flag3
Reprocessed and Reused Flag3
Health Professional3
Initial Report to FDA3
Report to FDA3
Event Location3
Manufacturer ContactMICHAEL COTE
Manufacturer Street1302 WRIGHTS LANE EAST
Manufacturer CityWEST CHESTER PA 19380
Manufacturer CountryUS
Manufacturer Postal19380
Manufacturer Phone6107195000
Manufacturer G1UMKIRCH
Manufacturer StreetIM KIRCHENHURSTLE 4
Manufacturer CityUMKIRCH B. FREIBURG D-79224
Manufacturer CountryGM
Manufacturer Postal CodeD-79224
Single Use3
Previous Use Code3
Event Type3
Type of Report3

Device Details

Brand NameDOUBLEAIRHOSE L5M F/SYST SYNTHES
Generic NameINSTRUMENT SURGICAL, ORTHO, PNEUMATIC, POWERED AND ACCESSORY/ATTACHMENT
Product CodeHSZ
Date Received2017-10-11
Returned To Mfg2017-10-17
Catalog Number519.530
Lot NumberN/A
OperatorHEALTH PROFESSIONAL
Device AvailabilityR
Device AgeDA
Device Eval'ed by MfgrY
Device Sequence No1
Device Event Key0
ManufacturerUMKIRCH
Manufacturer AddressIM KIRCHENHURSTLE 4 UMKIRCH B. FREIBURG D-79224 GM D-79224


Patients

Patient NumberTreatmentOutcomeDate
10 2017-10-11

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