MAUDE MDR 5866002

MDR report key
5866002
Report number
2183502-2016-01687
Event key
0
Event type
3
Date received
2016-08-10
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
1
Health professional
3
Initial report to FDA
3
Event location
3

Manufacturer Contact#

Contact
LISA PERZ
Address
1265 GREY FOX ROAD ST PAUL 55112 US
Phone
763-763-7633
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1WALLACE OOCYTE RECOVERY SYSTEMSNEEDLE, ASSISTED REPRODUCTIONSMITHS MEDICALMQEON17332732535Y *

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12016-08-1001. O

Event Narratives#

N

Patient 1

ADDITIONAL MANUFACTURER NARRATIVE: CUSTOMER HAS NOT YET RETURNED THE DEVICE TO THE MANUFACTURER FOR DEVICE EVALUATION. WHEN AND IF THE DEVICE BECOMES AVAILABLE AND IS RETURNED AND EVALUATED THE MANUFACTURER WILL FILE A FOLLOW-UP REPORT DETAILING THE RESULTS OF THE EVALUATION.

D

Patient 1

DISTRIBUTOR REPORTED THAT A PATIENT EXPERIENCED SEVERE ABDOMINAL PAIN AND HEAVY BLEEDING AFTER A PUNCTURE. DUE TO THE PAIN AND BLEEDING, THE PHYSICIAN INSPECTED THE NEEDLE WITH A MAGNIFYING GLASS AND OBSERVED IRREGULARITIES IN THE BEZEL. DURING THE PUNCTURE, NOTHING "STRANGE" WAS NOTICED. THE NEEDLES WERE COMPARED TO THOSE OF ANOTHER LOT, WHICH DID NOT PRESENT THE BEZEL IRREGULARITY. ADDITIONAL INFORMATION HAS BEEN REQUESTED MULTIPLE TIMES, IF RECEIVED, A FOLLOW UP WILL BE SENT.

N

Patient 1

(B)(4).

N

Patient 1

TWO USED SAMPLES WERE RECEIVED FOR INVESTIGATION. PHOTOGRAPHS WERE ALSO PROVIDED FOR EXAMINATION. A REVIEW OF THE PROVIDED PHOTOGRAPHS WAS UNABLE TO FIND DEFECT WITH THE DEVICES. THE INITIAL DEVICE WAS RECEIVED ON OCTOBER 21ST, 2016; HOWEVER THE SAMPLE WAS DETERMINED TO BE A DIFFERENT PART NUMBER THAN THE REPORTED DEVICE; THEREFORE, NO INVESTIGATION WAS ABLE TO BE PERFORMED. THE SECOND SAMPLE WHICH WAS RECEIVED ON DECEMBER 14TH, 2016 WAS CONFIRMED TO BE THE REPORTED PART NUMBER AND THEREFORE AN INVESTIGATION WAS PERFORMED. THE SAMPLE WAS RECEIVED INSIDE A PLASTIC BAG WITHOUT THE PROTECTOR SHEATH TO COVER THE TIP. THE RETURNED SAMPLE WAS EVALUATED USE A PROBE MICROSCOPE; THE SAMPLE WAS FOUND TO BE WITHIN SPECIFICATION. DURING FUNCTIONAL TESTING THE SAMPLE UNDERWENT PENETRATION EVALUATION; THE SAMPLE WAS FOUND TO BE WITHIN SPECIFICATION. INVESTIGATION DETERMINED THAT THE SAMPLE OPERATED WITHIN SPECIFICATION AND NO FAULT WAS FOUND. PLEASE NOTE: INITIAL SAMPLE WAS RECEIVED ON OCTOBER 21ST, 2016; HOWEVER, IT WAS DETERMINED TO BE THE INCORRECT PART NUMBER. THE SECOND SAMPLE WAS RECEIVED ON DECEMBER 14TH, 2016 AND WAS FOUND TO BE THE CORRECT PART NUMBER.

N

Patient 1

TWO USED WALLACE? WALLACE OOCYTE RECOVERY SYSTEMS SAMPLES WERE RECEIVED FOR INVESTIGATION. PHOTOGRAPHS WERE ALSO PROVIDED FOR EXAMINATION. A REVIEW OF THE PROVIDED PHOTOGRAPHS WAS UNABLE TO FIND DEFECT WITH THE DEVICES. THE INITIAL DEVICE WAS RECEIVED INSIDE A PLASTIC BAG ON OCTOBER 21ST, 2016. THE RETURNED SAMPLE WAS EVALUATED USING A PROBE MICROSCOPE; NO DAMAGE WAS OBSERVED WITH THE DEVICE NEEDLE TIP. A SECOND SAMPLE WAS RECEIVED INSIDE A PLASTIC BAG ON DECEMBER 14TH, 2016. THE SAMPLE WAS RECEIVED WITHOUT THE PROTECTIVE SHEATH TO COVER THE TIP. THE SECOND RETURNED SAMPLE WAS ALSO EVALUATED USE A PROBE MICROSCOPE; THE SAMPLE WAS FOUND TO BE WITHIN SPECIFICATION. DURING FUNCTIONAL TESTING THE SAMPLE UNDERWENT PENETRATION EVALUATION; THE SAMPLE WAS FOUND TO BE WITHIN SPECIFICATION. INVESTIGATION DETERMINED THAT BOTH RETURNED SAMPLES OPERATED WITHIN SPECIFICATION AND NO FAULT WAS FOUND. PLEASE NOTE: INITIAL SAMPLE WAS RECEIVED ON OCTOBER 21ST, 2016. THE SECOND SAMPLE WAS RECEIVED ON DECEMBER 14TH, 2016.

N

Patient 1

TWO USED SAMPLES WERE RECEIVED FOR INVESTIGATION. PHOTOGRAPHS WERE ALSO PROVIDED FOR EXAMINATION. A REVIEW OF THE PROVIDED PHOTOGRAPHS WAS UNABLE TO FIND DEFECT WITH THE DEVICES. THE INITIAL DEVICE WAS RECEIVED ON OCTOBER 21ST, 2016; HOWEVER THE SAMPLE WAS DETERMINED TO BE A DIFFERENT PART NUMBER THAN THE REPORTED DEVICE; THEREFORE, NO INVESTIGATION WAS ABLE TO BE PERFORMED. THE SECOND SAMPLE WHICH WAS RECEIVED ON DECEMBER 14TH, 2016 WAS CONFIRMED TO BE THE REPORTED PART NUMBER AND THEREFORE AN INVESTIGATION WAS PERFORMED. THE SAMPLE WAS RECEIVED INSIDE A PLASTIC BAG WITHOUT THE PROTECTOR SHEATH TO COVER THE TIP. THE RETURNED SAMPLE WAS EVALUATED USE A PROBE MICROSCOPE; THE SAMPLE WAS FOUND TO BE WITHIN SPECIFICATION. DURING FUNCTIONAL TESTING THE SAMPLE UNDERWENT PENETRATION EVALUATION; THE SAMPLE WAS FOUND TO BE WITHIN SPECIFICATION. INVESTIGATION DETERMINED THAT THE SAMPLE OPERATED WITHIN SPECIFICATION AND NO FAULT WAS FOUND. PLEASE NOTE: INITIAL SAMPLE WAS RECEIVED ON OCTOBER 21ST, 2016; HOWEVER, IT WAS DETERMINED TO BE THE INCORRECT PART NUMBER. THE SECOND SAMPLE WAS RECEIVED ON DECEMBER 14TH, 2016 AND WAS FOUND TO BE THE CORRECT PART NUMBER. (B)(4).