MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed with the FDA on 1994-06-08 for HULKA FALLOPIAN CLIP APPLICATOR 8986.01 manufactured by R. Wolf, Gmbh.
[20466977]
Surgeon was performing a hulka clip laparoscopic tubal ligation using our applicator, and the hulka clip fell out of the applicator into the pt's abdomen. A different applicator was used to complete the procedure. No pt complication. Invalid data - regarding single use labeling of device. Patient medical status prior to event: unknown. Invalid data - regarding multiple patient involvement. Invalid data - on device service/maintenance. No data - regarding date last serviced. Service provided by: invalid data. Invalid data - service records availability. No imminent hazard to public health claimed. Device used as labeled/intended. Invalid data - regarding evaluation by user after event. Method of evaluation: invalid data. Results of evaluation: invalid data. Conclusion: invalid data. Certainty of device as cause of or contributor to event: yes. Corrective actions: no data. Invalid data - on device destroyed/disposed of status.
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 1418479-1994-09077 |
| MDR Report Key | 25337 |
| Date Received | 1994-06-08 |
| Date of Report | 1994-05-25 |
| Date of Event | 1994-05-06 |
| Date Facility Aware | 1994-05-19 |
| Report Date | 1994-05-25 |
| Date Reported to FDA | 1994-05-25 |
| Date Reported to Mfgr | 1994-05-25 |
| Date Added to Maude | 1995-09-05 |
| Event Key | 0 |
| Report Source Code | Distributor report |
| Manufacturer Link | N |
| Number of Patients in Event | 0 |
| Adverse Event Flag | 3 |
| Product Problem Flag | 3 |
| Reprocessed and Reused Flag | 0 |
| Reporter Occupation | UNKNOWN |
| Health Professional | 3 |
| Initial Report to FDA | 3 |
| Report to FDA | 3 |
| Event Location | 3 |
| Single Use | 0 |
| Previous Use Code | 0 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | HULKA FALLOPIAN CLIP APPLICATOR |
| Generic Name | FALLOPIAN CLIP APPLICATOR |
| Product Code | HGD |
| Date Received | 1994-06-08 |
| Model Number | 8986.01 |
| Catalog Number | 8986.01 |
| Lot Number | NA |
| Operator | OTHER HEALTH CARE PROFESSIONAL |
| Device Availability | * |
| Implant Flag | * |
| Device Sequence No | 1 |
| Device Event Key | 25836 |
| Manufacturer | R. WOLF, GMBH |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 1. Other | 1994-06-08 |