MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a 06 report with the FDA on 2013-03-13 for KLEENSPEC 590 SERIES DISP VAGINAL SPECULA 59001 manufactured by Welch Allyn.
[3249158]
The customer stated that an add'l medium sized speculum had broken during a procedure. The customer states that lower blade had cracked. The pt was uninjured. The customer did not provide a pt identifier.
Patient Sequence No: 1, Text Type: D, B5
[10642366]
Welch allyn is reporting this in an abundance of caution. Unused product was returned for eval, however, the actual speculum involved in the event has been disposed of by the customer and therefore will not be returned to welch allyn. However, the complainant did provide a photograph of the broken speculum. The failure mode as described by the picture has been previously investigated. This device is a manually inserted, disposable vaginal speculum. The root cause of these very rare failures was determined to be related to potential impacts or loads on the shipping containers during transit or storage. No further investigation will be performed. Result: vaginal speculum). Conclusion: actual device not returned confirmed shipping damage by visual eval. Device mfr date: lot # 183346 was manufactured 08/12/2013 - 08/19/2013; lot # 185472 was manufactured 09/10/2013 - 09/17/2013.
Patient Sequence No: 1, Text Type: N, H10
| Report Number | 1316463-2013-00004 |
| MDR Report Key | 3040477 |
| Report Source | 06 |
| Date Received | 2013-03-13 |
| Date of Report | 2013-02-22 |
| Date of Event | 2013-02-22 |
| Date Mfgr Received | 2013-02-22 |
| Date Added to Maude | 2013-05-16 |
| 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 | 3 |
| Health Professional | 3 |
| Initial Report to FDA | 3 |
| Report to FDA | 0 |
| Event Location | 0 |
| Manufacturer Contact | PEARLEY BHAMBRI, DIR |
| Manufacturer Street | 4341 STATE ST. RD. PO BOX 220 |
| Manufacturer City | SKANEATELES FALLS NY 131530220 |
| Manufacturer Country | US |
| Manufacturer Postal | 131530220 |
| Manufacturer Phone | 3156852568 |
| Single Use | 3 |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | KLEENSPEC 590 SERIES DISP VAGINAL SPECULA |
| Product Code | HIB |
| Date Received | 2013-03-13 |
| Returned To Mfg | 2013-03-01 |
| Model Number | 59001 |
| Catalog Number | 59001 |
| Lot Number | 183346, 185472 |
| Operator | HEALTH PROFESSIONAL |
| Device Availability | Y |
| Device Age | DA |
| Device Eval'ed by Mfgr | Y |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | WELCH ALLYN |
| Manufacturer Address | 4341 STATE ST. RD. SKANEATELES FALLS NY 13153 US 13153 |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 2013-03-13 |