POLYSORB 170056

MAUDE Adverse Event Report

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 2020-01-29 for POLYSORB 170056 manufactured by Davis & Geck Caribe Ltd.

Event Text Entries

[179245668] If information is provided in the future, a supplemental report will be issued.
Patient Sequence No: 1, Text Type: N, H10


[179245669] According to the reporter, when closing the cuff towards the end of the procedure during a laparoscopic hand assisted vaginal hysterectomy, the needle broke while removing the device from the patient cavity at the trocar site. The surgeon continued as normal to complete the case. There was no patient injury.
Patient Sequence No: 1, Text Type: D, B5


MAUDE Entry Details

Report Number9612501-2020-00166
MDR Report Key9641266
Report SourceCOMPANY REPRESENTATIVE,HEALTH
Date Received2020-01-29
Date of Report2020-01-29
Date of Event2020-01-15
Date Mfgr Received2020-01-15
Device Manufacturer Date2015-10-30
Date Added to Maude2020-01-29
Event Key0
Report Source CodeManufacturer report
Manufacturer LinkY
Number of Patients in Event0
Adverse Event Flag3
Product Problem Flag3
Reprocessed and Reused Flag3
Reporter OccupationOTHER HEALTH CARE PROFESSIONAL
Health Professional3
Initial Report to FDA3
Report to FDA3
Event Location3
Manufacturer ContactLISA HERNANDEZ
Manufacturer Street60 MIDDLETOWN AVE.
Manufacturer CityNORTH HAVEN CT 06473
Manufacturer CountryUS
Manufacturer Postal06473
Manufacturer Phone2034925563
Manufacturer G1DAVIS & GECK CARIBE LTD
Manufacturer StreetZONA FRANCA DE SAN ISIDRO
Manufacturer CitySANTO DOMINGO 0101
Manufacturer CountryDO
Manufacturer Postal Code0101
Single Use3
Previous Use Code3
Event Type3
Type of Report3

Device Details

Brand NamePOLYSORB
Generic NameENDOSCOPIC TISSUE APPROXIMATION DEVICE
Product CodeOCW
Date Received2020-01-29
Model Number170056
Catalog Number170056
Lot NumberJ5K2529X
OperatorHEALTH PROFESSIONAL
Device AvailabilityN
Device Eval'ed by Mfgr*
Device Sequence No1
Device Event Key0
ManufacturerDAVIS & GECK CARIBE LTD
Manufacturer AddressZONA FRANCA DE SAN ISIDRO SANTO DOMINGO 0101 DO 0101


Patients

Patient NumberTreatmentOutcomeDate
10 2020-01-29

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