MAUDE MDR 8480591

MDR report key
8480591
Report number
3008770252-2019-00001
Event key
0
Event type
3
Date of event
2019-02-07
Date received
2019-04-03
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
2
Health professional
3
Initial report to FDA
3
Event location
3

Manufacturer Contact#

Contact
RUPANSHI NAIK
Address
700 COMMERCE DRIVE SUITE 500-118 OAK BROOK IL 60523 US
Phone
877-877-8778
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1NOVO SURGICAL MCIVOR MOUTH GAGMCIVOR MOUTH GAGNOVO SURGICAL INC.KBN4553-204553-20M4/17Y R

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12019-04-030

Event Narratives#

N

Patient 1

NOVO SURGICAL STARTED ITS PRELIMINARY INVESTIGATION BY OBTAINING ADDITIONAL INFORMATION FROM THE USER/FACILITY AND REQUESTING THAT THE AFFECTED PRODUCTS BE RETURNED. THE RETURNED PRODUCTS WERE EVALUATED BY NOVO SURGICAL'S QUALITY ASSURANCE FOR THEIR TENSILE STRENGTH TO DETERMINE IF THE PRODUCTS MET SPECIFICATION. ONCE THE FRAMES WERE SECURED PROPERLY TO THE HANDLES, THE EVALUATED DEVICES WERE ABLE TO WITHSTAND FORCE IN SIGNIFICANT EXCESS OF WHAT WOULD TYPICALLY BE ENCOUNTERED IN SURGERY. NO NON-CONFORMITIES WERE OBSERVED WITH THESE DEVICES. NOVO SURGICAL IDENTIFIED NO CORRECTIVE ACTIONS. IT IS POSSIBLE THAT THE FRAME WAS NOT AFFIXED SECURELY TO THE HANDLE AT THE TIME IT CAME APART AND/OR THAT THE USE OF AN ADULT FRAME ON A PEDIATRIC PATIENT CONTRIBUTED TO THE INJURY AS SIGNIFICANTLY MORE PRESSURE WOULD NEED TO BE APPLIED TO FIT AN ADULT GAG INTO THE MOUTH OF A PEDIATRIC PATIENT. A DEVICE HISTORY REVIEW UNCOVERED NO PREVIOUS RECORDED QUALITY PROBLEMS OR COMPLAINTS ASSOCIATED WITH THIS ITEM.

D

Patient 1

NOVO SURGICAL INC. RECEIVED A SUS VOLUNTARY EVENT REPORT FROM THE FDA (REPORT MW5084100) NOTIFYING IT OF A MDR SUBMITTED BY A USER/FACILITY WITH REGARDS TO A MCIVOR MOUTH GAG (ITEM NO. 4553-20) SUPPLIED BY NOVO SURGICAL. THE FDA CORRESPONDENCE DATED FEBRUARY 27, 2019 WAS DELIVERED VIA POSTAL MAIL AND RECEIVED BY NOVO SURGICAL ON MARCH 6, 2019. THIS WAS THE FIRST NOTIFICATION TO NOVO SURGICAL OF THIS COMPLAINT. THIS PRODUCT IS COMPRISED OF TWO PARTS (A FRAME AND HANDLE) THAT ARE TO BE ASSEMBLED TOGETHER WITH TWO DETACHABLE SCREWS WHEN IN USE. THE PRODUCT MAY BE DISASSEMBLED DURING STERILIZATION. IN THE SUS VOLUNTARY EVENT REPORT, THE USER/FACILITY HAD INDICATED THAT THE ITEM CAME APART AS IT WAS BEING POSITIONED IN A PEDIATRIC PATIENT'S MOUTH AND KNOCKED OUT ONE OF THE PATIENT'S FRONT TOP INCISORS AND SIGNIFICANTLY LOOSENED ANOTHER. USER/FACILITY ALSO REPORTED THAT ONE OF THE SCREWS OF THE MOUTH GAGS WAS FOUND TO BE MISSING AND NOT RECOVERED AND THAT X-RAY CONFIRMED THAT THE PATIENT DID NOT SWALLOW THE SCREW.