MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a distributor report with the FDA on 2015-12-04 for IVORY CLAMP 50057354 manufactured by Heraeus Kulzer, Llc.
[32693132]
Although we have not established that the device caused or contributed to the event, we're reporting it to be compliant with 21 cfr part 803 and out of an abundance of caution. " this malfunction is reportable as sec. 803. 50 states: if you are a manufacturer, you must report to us no later than 30 calendar days after the day that you receive or otherwise become aware of information, from any source, that reasonably suggests that a device that you market has malfunctioned and this device or a similar device that you market would be likely to cause or contribute to a death or serious injury if the malfunction were to recur. The malfunction will be reported to maintain compliance with 21 cfr 803 and out of an abundance of caution. The directions for use warns, "caution: modification, over-extending, bending, or use exceeding one year may cause breakage. "
Patient Sequence No: 1, Text Type: N, H10
[32693133]
Clamp returned to manufacturer by dealer with note that clamp broke on first use. This clamp was stamped a3 and returned in a bag stamped r5. Considering the actual manufacture date and the date of the package are 20 months different, it would appear the clamp returned had likely been in use for over a year. .
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 1821514-2015-00033 |
| MDR Report Key | 5267564 |
| Report Source | DISTRIBUTOR |
| Date Received | 2015-12-04 |
| Date of Report | 2015-11-12 |
| Date Mfgr Received | 2015-11-12 |
| Device Manufacturer Date | 2013-09-30 |
| Date Added to Maude | 2015-12-04 |
| 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 | 3 |
| Event Location | 3 |
| Manufacturer Contact | MS. RITA ROGERS |
| Manufacturer Street | 300 HERAEUS WAY |
| Manufacturer City | SOUTH BEND IN 46614 |
| Manufacturer Country | US |
| Manufacturer Postal | 46614 |
| Manufacturer Phone | 5742995409 |
| Manufacturer G1 | HERAEUS KULZER, LLC |
| Manufacturer Street | 300 HERAEUS WAY |
| Manufacturer City | SOUTH BEND IN 466142517 |
| Manufacturer Country | US |
| Manufacturer Postal Code | 466142517 |
| Single Use | 3 |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | IVORY CLAMP |
| Generic Name | CLAMP, RUBBER DAM |
| Product Code | EEF |
| Date Received | 2015-12-04 |
| Returned To Mfg | 2015-11-17 |
| Catalog Number | 50057354 |
| Lot Number | A3 |
| Device Expiration Date | 2018-09-30 |
| Operator | DENTIST |
| Device Availability | R |
| Device Eval'ed by Mfgr | Y |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | HERAEUS KULZER, LLC |
| Manufacturer Address | 300 HERAEUS WAY SOUTH BEND IN 466142517 US 466142517 |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 2015-12-04 |