MAUDE MDR 9708324

MDR report key
9708324
Report number
2126666-2020-00013
Event key
0
Event type
3
Date of event
2020-01-22
Date received
2020-02-13
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
MS. JACKIE OHNSORG
Address
340 LAKE HAZELTINE DRIVE CHASKA, MN US
Phone
641-641-6418
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1PREFORM GUIDEWIRE - SAFARI2WIRE GUIDELAKE REGION MEDICALDQXH74939406XS139406XS111181826Y R

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12020-02-130

Event Narratives#

N

Patient 1

THE SAFARI2 GUIDEWIRE IS EXPECTED TO BE RETURNED FOR EVALUATION BUT HAD NOT BEEN RECEIVED AT THE TIME THIS MEDWATCH REPORT WAS SUBMITTED. THE END USER DID PROVIDE LOT TRACEABILITY FOR THE SAFARI2 GUIDEWIRE USED IN THIS CASE. A REVIEW OF THE DEVICE HISTORY RECORDS OF THE SPECIMEN DEVICE DID NOT PRESENT ANY INDICATION OF MANUFACTURING DEFECT OR ANOMALY THAT COULD HAVE IMPACTED ON THE EVENT AS REPORTED. DURING MANUFACTURING AND PACKAGING OF THIS PRODUCT THE OPERATORS ARE INSTRUCTED TO 100% VISUALLY INSPECT FOR ANY OBVIOUS DEFECT PRIOR TO SHIPMENT. THE HISTORY RECORDS INDICATE THIS PRODUCT WAS FINAL INSPECTION TESTED AT LAKE REGION MEDICAL AND WAS DETERMINED TO BE ACCEPTABLE. AT THIS TIME, IT IS NOT POSSIBLE TO ASSIGN A DEFINITIVE ROOT CAUSE FOR THE EVENT AS REPORTED. IF ADDITIONAL INFORMATION IS RECEIVED OR THE PRODUCT IS RETURNED FOR ANALYSIS A FOLLOW-UP MEDWATCH REPORT WILL BE FILED.

D

Patient 1

AS REPORTED BY THE DISTRIBUTOR: EVENT DESCRIPTION: IT WAS REPORTED THAT: THEY TOOK THE SAFARI2 WIRE IN INTO THE LEFT VENTRICLE. THEY WERE ACTUALLY DOING A PROCEDURE CALLED A BASILICA. THIS WAS PART OF A BUNCH OF OTHER WIRES AND APPARENTLY THEY SNARED ACCIDENTALLY THE TIP OF THIS SAFARI2 WIRE AND THEY PULLED IT AND SO IT WAS UNRAVELING. THEY WERE ABLE TO GET IT OUT NO PROBLEM BUT SR JUST WANTED TO CALL IT IN AND MAKE SURE TO REPLACE THE DEVICE AS THEY WERE PRETTY NERVOUS ABOUT IT. THE CASE WAS COMPLETED FINE. THEY SWITCHED IN FOR ANOTHER WIRE (AMPLATZ) AND THAT WORKED FINE. THIS HAPPENED DURING THE PROCEDURE, INSIDE OF THE PATIENT'S BODY. NO COMPLICATIONS.