BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    MAMMOTOME REVOLVE STEREOTACTIC PROBE

    MDR report key: 8381515 · Received March 1, 2019

    Report

    Report Number
    3008492462-2019-00013
    Event Type
    Malfunction
    Date Received
    March 1, 2019
    Date of Event
    February 1, 2019
    Report Date
    March 1, 2019
    Manufacturer
    DEVICOR MEDICAL PRODUCTS, INC.
    Product Code
    KNW
    UDI-DI
    10841911100710
    PMA / PMN Number
    K152989
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    PA, US
    Reporter Occupation
    003

    Narratives

    Additional Manufacturer Narrative · 1

    MST1009 PROBES ARE STERILE, SINGLE USE DEVICES, INDICATED TO OBTAIN TISSUE SAMPLES FROM THE BREAST OR AXILLARY LYMPH NODES FOR DIAGNOSTIC ANALYSIS OF BREAST ABNORMALITIES. THE DEVICE WAS NOT RETURNED TO DEVICOR MEDICAL PRODUCTS, INC. FOR EVALUATION. THEREFORE WE ARE UNABLE TO DETERMINE A ROOT CAUSE FOR THE REPORTED INCIDENT. IF THE TISSUE IS FOUND WITHIN THE CANISTER RATHER THAN IN THE SAMPLE MANAGEMENT SYSTEM, A MISDIAGNOSIS IS POSSIBLE DUE TO LOST TISSUE. FOLLOWING CONSULTATION WITH OUR MEDICAL DIRECTOR, DUE TO THE POTENTIAL TO CAUSE OR CONTRIBUTE TO DEATH OR SERIOUS INJURY AS A RESULT OF POTENTIAL MISSED OR LOST TISSUE SAMPLES, PURSUANT TO 21 CFR §803, THIS FAILURE MODE WAS DETERMINED TO BE A REPORTABLE MALFUNCTION.

    Description of Event or Problem · 1

    DEVICOR MEDICAL PRODUCTS, INC. RECEIVED A REPORT STATING, "PROBE SUCKED TISSUE INTO THE CANISTER INSTEAD OF THE INDIVIDUAL CHAMBERS". NO PATIENT CONSEQUENCES REPORTED. THIS HAS BEEN DOCUMENTED IN OUR SYSTEM AS RECORD # (B)(4).

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    175913 MAMMOTOME REVOLVE STEREOTACTIC PROBE BIOPSY DEVICE KNW DEVICOR MEDICAL PRODUCTS, INC. MST0809 F11842503D 10841911100710

    Patients

    Seq Age Sex Outcome Treatment
    1