MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a 06 report with the FDA on 2005-09-30 for GYNECARE X-TRACT MORCELLATOR DV0015 manufactured by Ethicon, Inc..
[429523]
It was reported that a small piece of plastic (0. 5cm x 2mm) on the tip of the device was missing from the tip of the instrument immediately prior to taking patient to recovery. It was not known at what point the piece broke off. The piece could not located and it is unknown whether the piece was retained in the pt. There was no pt consequence.
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 2210968-2005-00581 |
| MDR Report Key | 638789 |
| Report Source | 06 |
| Date Received | 2005-09-30 |
| Date of Report | 2005-08-31 |
| Date of Event | 2005-08-16 |
| Date Facility Aware | 2005-08-16 |
| Report Date | 2005-08-31 |
| Date Mfgr Received | 2005-08-31 |
| Date Added to Maude | 2005-10-04 |
| 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 | MR. MARK YALE |
| Manufacturer Street | ROUTE 22 WEST P.O. BOX 151 |
| Manufacturer City | SOMERVILLE NJ 088760151 |
| Manufacturer Country | US |
| Manufacturer Postal | 088760151 |
| Manufacturer Phone | 9082182326 |
| Manufacturer G1 | ACCELENT |
| Manufacturer Street | 45 LEXINGTON DRIVE |
| Manufacturer City | LACONIA NH 03246 |
| Manufacturer Country | US |
| Manufacturer Postal Code | 03246 |
| Single Use | 3 |
| Previous Use Code | 3 |
| Removal Correction Number | NA |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | GYNECARE X-TRACT MORCELLATOR |
| Generic Name | MORCELLATOR |
| Product Code | HFG |
| Date Received | 2005-09-30 |
| Model Number | NA |
| Catalog Number | DV0015 |
| Lot Number | MS0305041 |
| ID Number | NA |
| Operator | HEALTH PROFESSIONAL |
| Device Availability | N |
| Device Age | UNKNOWN |
| Device Eval'ed by Mfgr | R |
| Implant Flag | N |
| Date Removed | A |
| Device Sequence No | 1 |
| Device Event Key | 628337 |
| Manufacturer | ETHICON, INC. |
| Manufacturer Address | ROUTE 22 WEST P.O. BOX 151 SOMERVILLE NJ 088760151 US |
| Baseline Brand Name | GYNECARE LAPAROSCOPIC MORCELLATOR |
| Baseline Generic Name | LAPAROSCOPIC MORCELLATOR |
| Baseline Model No | NA |
| Baseline Catalog No | DV0015 |
| Baseline ID | NA |
| Baseline Device Family | GYNECARE LAPAROSCOPIC MORCELLATOR |
| Baseline Shelf Life Contained | Y |
| Baseline Shelf Life [Months] | 12 |
| Baseline PMA Flag | N |
| Baseline 510K PMN | Y |
| Premarket Notification | K963872 |
| Baseline Preamendment | N |
| Baseline Transitional | N |
| 510k Exempt | N |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 1. Other | 2005-09-30 |