MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a 00 report with the FDA on 1999-12-17 for OSTIUM PUNCH BACKWARD BITING FORCEPS 8211.08 manufactured by Richard Wolf Gmbh.
[176823]
The blade or jaw of an ostium punch forceps broke off during sinus surgery. The small metal piece was retrieved. No injury to the pt was reported.
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 1418479-1999-00054 |
| MDR Report Key | 255653 |
| Report Source | 00 |
| Date Received | 1999-12-17 |
| Date of Report | 1999-11-19 |
| Date of Event | 1999-11-19 |
| Date Facility Aware | 1999-11-19 |
| Report Date | 1999-11-19 |
| Date Reported to Mfgr | 1999-11-19 |
| Date Mfgr Received | 1999-11-19 |
| Date Added to Maude | 1999-12-27 |
| Event Key | 0 |
| Report Source Code | Manufacturer report |
| Manufacturer Link | Y |
| Number of Patients in Event | 0 |
| Adverse Event Flag | 3 |
| Product Problem Flag | 3 |
| Reprocessed and Reused Flag | 0 |
| Health Professional | 3 |
| Initial Report to FDA | 3 |
| Report to FDA | 3 |
| Event Location | 3 |
| Manufacturer Contact | JERRY BALOK |
| Manufacturer Street | 353 CORPORATE WOODS PARKWAY |
| Manufacturer City | VERNON HILLS IL 60061 |
| Manufacturer Country | US |
| Manufacturer Postal | 60061 |
| Manufacturer Phone | 8479131113 |
| Manufacturer G1 | RICHARD WOLF GMBH |
| Manufacturer Street | PFORZHEIMER STR. 32 |
| Manufacturer City | KNITTLINGEN D 75438 |
| Manufacturer Country | GM |
| Manufacturer Postal Code | D 75438 |
| Single Use | 3 |
| Remedial Action | OT |
| Previous Use Code | 3 |
| Removal Correction Number | NA |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | OSTIUM PUNCH BACKWARD BITING FORCEPS |
| Generic Name | OSTIUM PUNCH BACKWARD BITING FORCEPS |
| Product Code | KTF |
| Date Received | 1999-12-17 |
| Model Number | 8211.08 |
| Catalog Number | 8211.08 |
| Lot Number | UNK |
| ID Number | NA |
| Operator | HEALTH PROFESSIONAL |
| Device Availability | Y |
| Device Age | UNKNOWN |
| Device Eval'ed by Mfgr | R |
| Implant Flag | N |
| Date Removed | A |
| Device Sequence No | 1 |
| Device Event Key | 247553 |
| Manufacturer | RICHARD WOLF GMBH |
| Manufacturer Address | PFORZHEIMER STR. 32 KNITTLINGEN GM D 75438 |
| Baseline Brand Name | OSTIUM PUNCH BACKWARD BITING FORCEPS |
| Baseline Generic Name | OSTIUM PUNCH BACKWARD BITING FORCEPS |
| Baseline Model No | 8211.08 |
| Baseline Catalog No | 8211.08 |
| Baseline ID | UNK |
| Baseline Device Family | OSTIUM PUNCH |
| Baseline Shelf Life [Months] | NA |
| Baseline PMA Flag | N |
| Baseline 510K PMN | N |
| Baseline Preamendment | N |
| Baseline Transitional | N |
| 510k Exempt | Y |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 1999-12-17 |