MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a company representative,health report with the FDA on 2016-12-21 for MIC1332 manufactured by Sterilmed, Inc..
[63072799]
The device has not yet been returned to the manufacturer at the time of this report. A supplemental form will be sent once the evaluation is completed if the device is returned. The device history report was reviewed and no discrepancies were found.
Patient Sequence No: 1, Text Type: N, H10
[63072800]
It was reported that the biopsy forceps device was tested prior to entering the patient. During the procedure, the device broke when it was opened to retrieve the biopsy. It was reported that there was no evidence that the patient was harmed during this incident and no evidence that any part of the biopsy was left in or broke off inside the patient.
Patient Sequence No: 1, Text Type: D, B5
[65821643]
The complaint device was subjected to full functional testing. No defect was detected. No overt damage was detected. The account's complaint could not be confirmed. No defect found.
Patient Sequence No: 1, Text Type: N, H10
| Report Number | 2134070-2016-00092 |
| MDR Report Key | 6195532 |
| Report Source | COMPANY REPRESENTATIVE,HEALTH |
| Date Received | 2016-12-21 |
| Date of Report | 2016-11-30 |
| Date of Event | 2016-11-28 |
| Date Mfgr Received | 2017-01-25 |
| Device Manufacturer Date | 2016-09-15 |
| Date Added to Maude | 2016-12-21 |
| 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 | JASON ANDERSON |
| Manufacturer Street | 5010 CHESHIRE PARKWAY SUITE 2 |
| Manufacturer City | PLYMOUTH MN 55446 |
| Manufacturer Country | US |
| Manufacturer Postal | 55446 |
| Manufacturer Phone | 7634888348 |
| Single Use | 3 |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Generic Name | FORCEPS, BIOPSY, NON-ELECTRIC, REPROCESSED |
| Product Code | NON |
| Date Received | 2016-12-21 |
| Returned To Mfg | 2017-01-25 |
| Model Number | MIC1332 |
| Catalog Number | MIC1332 |
| Lot Number | 1967305 |
| Device Expiration Date | 2017-09-15 |
| Operator | HEALTH PROFESSIONAL |
| Device Availability | R |
| Device Age | DA |
| Device Eval'ed by Mfgr | Y |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | STERILMED, INC. |
| Manufacturer Address | 11400 73RD AVE N MAPLE GROVE MN US |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 2016-12-21 |