Find a safety record
Every incident, injury and recall on file, from the national registries that publish them. Search a maker, a model, a town or a reference number — or narrow by what happened. Each record is the registry's own text, reproduced without rewriting, with the reference that locates it at the source. Registries count different things, so a total is a count of FILINGS and never a measure of how dangerous something is. How the record was collected.
Or jump to a maker
6,008 records on file
362 death reports1987–202614 registries
Narrow it down
What happened
Country
Year
Not graded by the source2020-08-24FDA MAUDEIntuitive Surgical, Inc.da Vinci Surgical System2955842-2020-10915da Vinci Surgical System
da Vinci Surgical System — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: IT WAS REPORTED THAT THERE WAS EXCESSIVE MOBILITY OF THE TIP COVER CAUSING IT TO FALL INTO THE SURGICAL SITE. THE TIP COVER WAS RETRIEVED AND THERE WAS NO CONSEQUENCES TO THE PATIENT. INTUITIVE SURGICAL, INC. (ISI) PERFORMED MULTIPLE FOLLOW-UP ATTEMPTS TO OBTAIN ADDITIONAL INFORMATION RELATED TO THIS EVENT. HOWEVER, AS OF THE DATE OF THIS REPORT, NO MORE DETAILS HAVE BEEN PROVIDED.
cause not established2955842-2020-10915Intuitive Surgical, Inc.da Vinci Surgical SystemRead the record ↗Not graded by the source2020-08-24FDA MAUDEMedtronic plc — Surgical RoboticsMazor X3005075696-2020-00109Mazor X
Mazor X — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: MEDTRONIC RECEIVED INFORMATION REGARDING A GUIDANCE SYSTEM BEING USED DURING A SPINAL PROCEDURE. IT WAS REPORTED THAT A POST-OP SCAN SHOWED THAT LEFT L1-L3 SCREWS WERE DEVIATED LATERALLY BETWEEN 3.5-10 MM. DURING THE IMPLANT PROCEDURE, A SINGLE SCHANZ PIN WAS USED TO MOUNT THE SURGICAL SYSTEM TO THE PATIENT. THE LEFT SIDE WAS DONE FIRST AND THE RIGHT SIDE WAS SECOND. THE THORACIC SCREWS ON THE RIGHT SIDE WERE ACCURATE. INTRA-OP IMAGING WAS DONE AND THE IMAGES LOOKED GOOD. THE MANUFACTURER REPRESENTATIVE THOUGHT THERE COULD BE A SHIFT THAT CAUSED THE DEVIATION. THE PATIENT EXPERIENCED SOME DISCOMFORT AFTER THE PROCEDURE AND THEY WERE BROUGHT BACK IN FOR A REVISION TO REPOSITION THE SCREWS ON THE FOLLOWING DAY. THE PROCEDURE WAS DELAYED LESS THAN AN HOUR.
cause not established3005075696-2020-00109Medtronic plc — Surgical RoboticsMazor XRead the record ↗Not graded by the source2020-08-21FDA MAUDEGlobus MedicalExcelsiusGPS3004142400-2020-00108ExcelsiusGPS
ExcelsiusGPS — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: IT WAS REPORTED THAT 4 SCREWS AT L2, L3, L5, AND S1 WERE NOT PLACED ACCORDING TO PLAN. THE SCREWS WERE REMOVED AND REPOSITIONED INTRA-OPERATIVELY.
cause not established3004142400-2020-00108Globus MedicalExcelsiusGPSRead the record ↗Not graded by the source2020-08-21FDA MAUDEIntuitive Surgical, Inc.da Vinci Surgical System2955842-2020-10930da Vinci Surgical System
da Vinci Surgical System — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: IT WAS INITIALLY REPORTED THAT DURING A DA VINCI-ASSISTED LOW ANTERIOR RESECTION PROCEDURE, A BURN INJURY WAS IDENTIFIED ON THE SMALL INTESTINE. THE INTRA-OPERATIVE COMPLICATION WAS FOUND WHILE THE SURGEON WAS CHECKING FOR BLEEDING TOWARDS THE END OF THE PROCEDURE. AFTER THE BURN INJURY WAS IDENTIFIED, THE SURGICAL STAFF INSPECTED THE MONOPOLAR CURVED SCISSORS (MCS) TIP COVER ACCESSORY THAT WAS INSTALLED ON A MCS INSTRUMENT AND IDENTIFIED A HOLE. THE SITE BELIEVES THE BURN INJURY WAS RELATED TO THE HOLE FOUND ON THE MCS TIP COVER ACCESSORY. THE SURGICAL PROCEDURE WAS COMPLETED ROBOTICALLY WITH A BACKUP INSTRUMENT/ACCESSORY. ON 28-AUG-2020, INTUITIVE SURGICAL, INC. (ISI) OBTAINED THE FOLLOWING ADDITIONAL INFORMATION REGARDING THE REPORTED EVENT FROM THE SURGEON AND A NURSE: THE ISI CLINICAL SALES REPRESENTATIVE (CSR) REPORTEDLY REVIEWED A VIDEO OF THE PROCEDURE WITH THE SURGEON. PER THE CSR, A COLLISION WAS OBSERVED INTRA-OPERATIVELY BETWEEN THE MCS INSTRUMENT AND A TIP-UP FENESTRATED GRASPER INSTRUMENT INSTALLED ON ARM #4. THE MCS TIP COVER ACCESSORY WAS REPORTEDLY HIT AND A HOLE WAS IDENTIFIED IN THE GREY AREA OF THE TIP COVER. DURING THE COURSE OF THE PROCEDURE, ARCING OF ELECTRI
cause not established2955842-2020-10930Intuitive Surgical, Inc.da Vinci Surgical SystemRead the record ↗Not graded by the source2020-08-19FDA MAUDEIntuitive Surgical, Inc.da Vinci Surgical System2955842-2020-10927da Vinci Surgical System
da Vinci Surgical System — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: IT WAS REPORTED THAT DURING A DA VINCI-ASSISTED SURGICAL PROCEDURE, A MONOPOLAR CURVED SCISSORS (MCS) TIP COVER ACCESSORY FELL INSIDE OF THE PATIENT. THE CUSTOMER STATED THAT THE PATIENT HAD A VERY LARGE UTERUS WHICH MADE THE CASE VERY DIFFICULT. THE MCS INSTRUMENT WAS DIFFICULT TO REMOVE; THE CUSTOMER FELT TENSION AND IT WAS NOTED THAT THE MCS TIP COVER ACCESSORY WAS MISSING. THE CUSTOMER PERFORMED AN X-RAY PRIOR TO CLOSING THE PATIENT AND THE MCS TIP COVER ACCESSORY WAS NOT IDENTIFIED. A CT SCAN WITHOUT CONTRAST WAS ALSO PERFORMED POST-PROCEDURE. THE MCS TIP COVER ACCESSORY WAS STILL MISSING AND IT WAS NOT CONFIRMED IF IT WAS INSIDE OF THE PATIENT. THE PROCEDURE WAS COMPLETED WITH NO REPORTED INJURY. INTUITIVE SURGICAL, INC. (ISI) MADE MULTIPLE FOLLOW-UP ATTEMPTS TO OBTAIN ADDITIONAL INFORMATION. HOWEVER, NO FURTHER DETAILS HAVE BEEN RECEIVED AS OF THE DATE OF THIS REPORT.
cause not established2955842-2020-10927Intuitive Surgical, Inc.da Vinci Surgical SystemRead the record ↗Not graded by the source2020-08-19FDA MAUDEZimmer Biomet3009185973-2020-00207ROSA Robotic Surgery
ROSA Robotic Surgery — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: DURING SURGERY, BUT PRIOR TO FIRST INCISION, THE INSTRUMENT HOLDER (B)(6) COULD NOT BE PLACED ONTO THE END OF THE ROBOT ARM BY THE SURGEON. UPON FURTHER INSPECTION, THERE APPEARED TO BE NOTCHES/GROOVES AROUND THE CENTER INSET CIRCLE THAT FITS ONTO THE ROBOT ARM. THE INSTRUMENT HOLDER HAD TO BE FILED DOWN AROUND THIS CIRCLE INSET IN ORDER TO GET THE INSTRUMENT HOLDER TO SIT FLUSH ONTO THE ROBOT ARM. IT WAS DETERMINED THAT THE ROBOT ARM HAD NO ISSUE AS THE POINTER PROBE AND LASER ATTACHMENTS SAT FLUSH WITH NO FORCE NEEDED. THE PROCESS OF GETTING THE INSTRUMENT HOLDER ATTACHED TO THE ROBOT ARM DELAYED SURGERY BY 30-45 MINUTES WHILE THE PATIENT WAS UNDER ANESTHESIA.
cause not established3009185973-2020-00207Zimmer BiometRead the record ↗Not graded by the source2020-08-19FDA MAUDEStryker3005985723-2021-00006Mako Robotic-Arm
Mako Robotic-Arm — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: THIS PI IS FOR THE CLOSED REDUCTION ON (B)(6) 2020. AS REPORTED: "PT DISCHARGED TO INPATIENT REHAB (B)(6) 2020. ON (B)(6) 2020 PT OUT OF BED UNASSISTED, BENT OVER TO PICK SOMETHING UP OFF FLOOR AND FELT SHARP PAIN IN HIP. XRAY SHOWED DISLOCATION, PT TAKEN TO OR FOR CLOSED REDUCTION. PT DISCHARGED HOME (B)(6) 2020. ON (B)(6) 2020 PT PRESENTED TO EMERGENCY DEPARTMENT WITH COMPLAINT OF HIP PAIN & SWELLING - PT ADMITTED W/ CELLULITIS. PT TO OPERATING ROOM (B)(6) 2020 FOR I&D - POSITIVE WOUND CULTURE - DEEP SURGICAL SITE INFECTION. PT LEFT AGAINST MEDICAL ADVICE POST-OP."
cause not established3005985723-2021-00006StrykerRead the record ↗Not graded by the source2020-08-19FDA MAUDEIntuitive Surgical, Inc.da Vinci Surgical System2955842-2020-11334da Vinci Surgical System
da Vinci Surgical System — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: ON 12-NOV-2020, INTUITIVE SURGICAL, INC. (ISI) RECEIVED MW 5096343 STATING: "SCISSOR TIP SHEATH ON INTUITIVE SCISSORS COMES OFF DURING SURGICAL PROCEDURE. FDA SAFETY REPORT ID#: (B)(4)." ISI MADE MULTIPLE FOLLOW-UP ATTEMPTS TO OBTAIN ADDITIONAL INFORMATION. HOWEVER, NO FURTHER DETAILS HAVE BEEN RECEIVED AS OF THE DATE OF THIS REPORT.
cause not established2955842-2020-11334Intuitive Surgical, Inc.da Vinci Surgical SystemRead the record ↗Not graded by the source2020-08-18FDA MAUDEGlobus MedicalExcelsiusGPS3004142400-2024-00480ExcelsiusGPS
ExcelsiusGPS — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: IT WAS ANOTHER PREOP CASE IN (B)(6), SCREWS REVISION S1L AND S1R. THE FF WAS ATTACHED IN THE CENTER WITHOUT THE GAP BETWEEN THE DETECTOR AND FF. I HAVE CHECKED THE MARKER'S POSTS ON THE FF AND THE GPS INSTRUMENTS, AND NO BENT POSTS WERE SEEN. DRB AND SM WERE PLACED AS USUAL ON THE RIGHT AND LEFT SIDE. DESPITE A GOOD REGISTRATION SCORE(8,9), WE GOT SHIFT IN THE AP SHOTS. NOTHING WAS MOVED DURING THE REGISTRATION, THE C-ARM WAS BRAKED, AND THE PATIENT AND TABLE WERE NOT MOVED. DURING THE X-RAYS THE MOVEMENT BAR WAS MOVING FROM GREEN TO YELLOW. WE TOOK A SECOND ATTEMPT, AND TRIED TO GET THE SHOTS, HAVING THE GREEN BAR. AFTER NEW LATERAL SHOOTS THE MERGE WAS GOOD, AND WE COULD PROCEED TO THE NAVIGATION. 3. AT THIS POINT THE SM TURNED TO RED AND THEN TO YELLOW, DESPITE NOTHING BEING MOVED OR CHANGED. THE SURGEON CHECKED THE NAVIGATION ACCURACY AT THE SKIN LEVEL AND DECIDED TO DO THE SKIN INCISION, WITHOUT TO RESET THE SM. HE CHECKED THE ACCURACY INSIDE THE WOUND, TAPING THE SPINAL PROCESS AND SCREWS HEADS. THE ACCURACY WAS GOOD, AND SM WAS DEACTIVATED AND ACTIVATED AGAIN AND WAS GREEN. DURING THE CASE, SURGEON CHECKED MULTIPLE TIMES THE NAVIGATION ACCURACY AND IT WAS GOOD. THE CONTROL X
cause not established3004142400-2024-00480Globus MedicalExcelsiusGPSRead the record ↗Not graded by the source2020-08-17FDA MAUDEIntuitive Surgical, Inc.da Vinci Surgical System2955842-2020-10758da Vinci Surgical System
da Vinci Surgical System — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: REFER TO H10/H11 FOR FOLLOW-UP INFORMATION.
cause not established2955842-2020-10758Intuitive Surgical, Inc.da Vinci Surgical SystemRead the record ↗Not graded by the source2020-08-17FDA MAUDEIntuitive Surgical, Inc.da Vinci Surgical System2955842-2022-12499da Vinci Surgical System
da Vinci Surgical System — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: IT WAS REPORTED THAT DURING A DA VINCI-ASSISTED SACROCOLPOPEXY WITH HYSTERECTOMY PROCEDURE, THE SYSTEM LOST POWER MID- PROCEDURE. THE SYSTEM HAD AN UNSPECIFIED NON-RECOVERABLE FAULT AND THE ARMS WERE RED. THE SURGEON ELECTED NOT TO POWER CYCLE OR ATTEMPT TO RECOVER AND INSTEAD, DECIDED TO CONVERT THE PROCEDURE TO TRADITIONAL LAPAROSCOPY DUE TO THE FACILITY POWER LOSS. THE SURGEON MENTIONED THAT THERE WAS A POSSIBLE PATIENT INJURY; HOWEVER, NO DETAILS WERE PROVIDED REGARDING THE POTENTIAL INJURY. THE INTUITIVE SURGICAL INC. (ISI) FIELD SERVICE ENGINEER (FSE) FOLLOWED UP WITH THE CUSTOMER ABOUT THE POWER LOSS AND WAS INFORMED THAT A LIGHTNING STRIKE CAUSED THE POWER OUTAGE TO THE ENTIRE OPERATING ROOM (OR). WHEN THE POWER OUTAGE OCCURRED, THE PATIENT SIDE CART (PSC) REVERTED TO BATTERY BACKUP AS DESIGNED. WHEN THE POWER WAS RESTORED, THE SYSTEM BOOTED BACK UP BECAUSE OF THE PSC STILL BEING ON AND THE SYSTEM GENERATED A NON-RECOVERABLE ERROR DUE TO THE LOSS OF COMMUNICATION TO THE VISION SIDE CART (VSC). THE CUSTOMER POWER CYCLED ALL SUBSYSTEMS, AND BROUGHT THEM UP TOGETHER, AND THE SYSTEM WORKED PROPERLY. PER THE FSE, THE SYSTEM WAS WORKING AS INTENDED AND NO ADDITIONAL ACTION WAS RE
cause not established2955842-2022-12499Intuitive Surgical, Inc.da Vinci Surgical SystemRead the record ↗Not graded by the source2020-08-17FDA MAUDEZimmer Biomet3009185973-2020-00201ROSA Robotic Surgery
ROSA Robotic Surgery — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: DURING SURGERY, THE ROSA SOFTWARE SHUTDOWN. UPON RESTART, THE CONTROLLER WOULD NOT CONNECT. THE SURGEON, NOTIFIED THE CLINICAL REPRESENTATIVE. THE SITE WAS INSTRUCTED TO POWER OFF THE ROBOT PC, SWITCH THE CONTROLLER SWITCH TO THE OFF POSITION, AND UNPLUG THE POWER CORD FROM THE WALL FOR 30 SECONDS. UPON RESTART, THE CONTROLLER DID CONNECT AND THE CASE COULD CONTINUE. THIS INCIDENT DID CAUSE A DELAY IN OF ABOUT 30 MINUTES TO THE SURGERY WHILE THE PATIENT WAS ALREADY IN THE ROOM AND ASLEEP.
cause not established3009185973-2020-00201Zimmer BiometRead the record ↗Serious injury2020-08-16OSHA129040.015
At 10:04 a.m. on August 16, 2020, an employee was unsticking a pallet and adjusting sensors on an industrial robot. The sensors were activated causing the robot to begin its cycle. The robot grabbed the employee and pulled him to the floor attempting to complete its cycle. The employee's leg was broken and required hospitalization for treatment.
cause attributed by source129040.015Read the record ↗Not graded by the source2020-08-15FDA MAUDEIntuitive Surgical, Inc.da Vinci Surgical System2955842-2023-16946da Vinci Surgical System
da Vinci Surgical System — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: DURING REVIEW OF A LITERATURE ARTICLE INVOLVING DA VINCI ASSISTED ROBOTIC PROCEDURES TITLED, ¿ROBOT-ASSISTED SPLEEN PRESERVING DISTAL PANCREATECTOMY (RA-SPDP): A SINGLE CENTER EXPERIENCE,¿ THE FOLLOWING EVENTS WERE REPORTED: A RETROSPECTIVE DATABASE ANALYSIS OF 54 PATIENTS WHO RECEIVED RA-SPDP BETWEEN APRIL 2008 TO OCTOBER 2017 AT A SINGLE INSTITUTION SHOWED OPERATIVE COMPLICATIONS AS FOLLOWS: INTRA-OPERATIVELY OUTCOME MEASURES SHOWED FOUR (7.4%) PATIENTS RECEIVED BLOOD TRANSFUSION, THE MEDIAN NUMBER OF BLOOD UNIT TRANSFUSED PER PATIENT WAS 1 UNIT. ADDITIONALLY, THE ARTICLE STATES, "IN THREE PATIENTS, THE SPLENIC VESSELS HAD TO BE RECONSTRUCTED TO AVOID A WARSHAW PROCEDURE OR A SPLENECTOMY. FURTHERMORE, THE ARTICLE NOTES, "THERE WERE TWO ELECTIVE RECONSTRUCTIONS, CAUSED BY DIFFICULT DETACHMENT OF THE SPLENIC VESSELS FROM THE TUMOR AND ONE URGENT RECONSTRUCTION DUE TO INJURY TO THE SPLENIC VEIN." POST-OPERATIVE OUTCOME MEASURES SHOWED FIVE PATIENTS REQUIRED POST-OPERATIVE BLOOD TRANSFUSIONS AND 21 PATIENTS HAD GRADE 0 CLAVIEN-DINDO COMPLICATIONS, 32 PATIENTS DEVELOPED GRADE I-II COMPLICATIONS AND 1 PATIENT HAD A CLAVIEN-DINDO GRADE III-IV COMPLICATION. IT WAS MENTIONED THAT TWO PATI
cause not established2955842-2023-16946Intuitive Surgical, Inc.da Vinci Surgical SystemRead the record ↗Not graded by the source2020-08-14FDA MAUDEIntuitive Surgical, Inc.da Vinci Surgical System2955842-2020-10955da Vinci Surgical System
da Vinci Surgical System — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: IT WAS REPORTED THAT AFTER COMPLETION OF A DA VINCI-ASSISTED PANCREATICODUODENECTOMY PROCEDURE, A PSEUDOANEURYSM ALLEGEDLY OCCURRED DUE TO A POST-OPERATIVE PANCREATIC LEAK. IT WAS NOTED THAT A BRANCHED BLOOD VESSEL FROM THE SUPERIOR MESENTERIC ARTERY (SMA) HAD ¿BEEN LEFT CUT OFF BY THE SYNCHROSEAL¿ INSTRUMENT AFTER SEALING AND A PANCREATIC LEAK OCCURRED IN THE SURROUNDING AREA. FURTHERMORE, THE TISSUE TREATED WITH THE SYNCHROSEAL INSTRUMENT WAS BURNED AND APPEARED WHITE. IT WAS SUSPECTED THAT IT WAS DUE TO DAMAGE TO ¿J1V¿ (FIRST JEJUNAL VEIN). THE SURGEON COMMENTED THAT HE/SHE SHOULD HAVE USED THE SYNCHROSEAL INSTRUMENT WITH CAUTION. ON 27-AUG-2020, INTUITIVE SURGICAL, INC. (ISI) OBTAINED THE FOLLOWING ADDITIONAL INFORMATION REGARDING THE REPORTED EVENT: THE DA VINCI-ASSISTED SURGICAL PROCEDURE WAS RECORDED ON VIDEO. HOWEVER, THE SITE CANNOT PROVIDE THE VIDEO TO ISI FOR REVIEW. IT WAS EXPLAINED THAT AFTER A BRANCHED VESSEL FROM THE SMA WAS SEALED COMPLETELY WITH THE SYNCHROSEAL INSTRUMENT, THE SURGEON THEN CUT THE VESSEL. ALTHOUGH IT WAS NOTED THAT THE SITE BELIEVES NO MALFUNCTION OF THE SYNCHROSEAL INSTRUMENT OCCURRED, THE SITE CLAIMS THAT THE SYNCHROSEAL INSTRUMENT HAS A LARGE TH
cause not established2955842-2020-10955Intuitive Surgical, Inc.da Vinci Surgical SystemRead the record ↗Not graded by the source2020-08-13FDA MAUDEMedtronic plc — Surgical RoboticsMazor X3005075696-2020-00106Mazor X
Mazor X — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: MEDTRONIC RECEIVED INFORMATION REGARDING A GUIDANCE SYSTEM BEING USED INTRA-OPERATIVELY OF A SPINAL PROCEDURE. IT WAS REPORTED THAT A SCREW DEVIATION WAS DISCOVERED. THE SCREWS WERE IMPLANTED DURING A L3-L4 CASE ON (B)(6) 2020 WITH NO ISSUES. THE SITE HAD TAKEN AP SHOTS TO CONFIRM SCREW PLACEMENT AFTER THE CASE; HOWEVER, THEY WERE UNABLE TO IDENTIFY THE DEVIATION FROM THOSE SHOTS. ON (B)(6) 2020, IT WAS DISCOVERED THAT THERE WAS A DEVIATION WHEN THE PA DID A FOLLOW UP VISIT WITH THE PATIENT SINCE THEY WERE STILL EXPERIENCING NERVE PAIN AND WEAKNESS IN THEIR LEGS. IT APPEARS THAT THE LEFT AND RIGHT L3 SCREWS ARE LATERAL BY 6 MM AND ARE NOT WITHIN THE PEDICLE. THE RIGHT L4 IS LATERAL BY 6 MM. BOTH MEASUREMENTS ARE APPROXIMATE FROM THE DISTAL END OF THE SCREW. THE REVISION PROCEDURE HAD NOT BEEN SCHEDULED. THE INITIAL PROCEDURE WAS NOT DELAYED.
cause not established3005075696-2020-00106Medtronic plc — Surgical RoboticsMazor XRead the record ↗Not graded by the source2020-08-10FDA MAUDEMedtronic plc — Surgical RoboticsMazor X3005075696-2020-00108Mazor X
Mazor X — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: ADDITIONAL INFORMATION RECEIVED FROM A MANUFACTURER REPRESENTATIVE REPORTED THAT L5 WAS ACTUALLY S1 AND THE L4 AND S1 SCREWS HAD EQUAL SHIFTS OFF THE CENTER OF THE PEDICLE.
cause not established3005075696-2020-00108Medtronic plc — Surgical RoboticsMazor XRead the record ↗Not graded by the source2020-08-10FDA MAUDEZimmer Biomet3009185973-2020-00199ROSA Robotic Surgery
ROSA Robotic Surgery — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: THE CLINICAL REPRESENTATIVE REPORTED THAT : 'AFTER THE 4TH ELECTRODE WAS PLACED IN AN SEEG SURGERY, THE ROBOT ARM WAS MOVED TO THE 5TH TRAJECTORY. THE RESIDENT NOTED THAT THE ENTRY POINT WOULD HIT THE PREVIOUSLY PLACED BOLT WHICH DID NOT MATCH THE PLAN. THE TRAJECTORY WAS SKIPPED AND THE ARM WAS MOVED TO THE NEXT TRAJECTORY. THE RESIDENT NOTED THAT THE ARM POINTED TO A SPOT ONE MM AWAY FROM THE MARK MADE PRIOR TO DRAPING. SEVERAL OTHER POINTS WERE CHECKED AND ALL APPEARED TO BE OFF IN DIFFERENT DIRECTIONS AND BETWEEN 1 ¿ 5MM. THE SURGEON DECIDED TO BREAK THE STERILE DRAPES TO TAKE AN INTRAOP CT WITH THE AIRO TO CHECK THE PLACEMENTS. ALL LOCKS WERE CHECKED ON THE ROBOT AND HEAD FRAME AND IT APPEARED THE LEKSELL HEAD FRAME WAS LOOSE AT THE LEKSELL ADAPTOR (THE PIECE THAT CONNECTS THE LEKSELL FRAME TO THE ROSA MAYFIELD ADAPTOR). THE SURGEON WHO FIXATED THE FRAME SAID THAT HE WAS CERTAIN IT WAS NOT LIKE THIS PRIOR TO SURGERY AND THAT HE HAD CONFIRMED IT WAS LOCKED. A SCAN WAS TAKEN AND THE FOUR PLACED ELECTRODES ALIGNED WITH THE PLANNED TRAJECTORIES. THE SURGEON RE-REGISTERED WITH FRAME REGISTRATION. THE POSTOP SCAN SHOWED THE MAJORITY OF THE REMAINING TRAJECTORIES WERE PLACED CORRECTL
cause not established3009185973-2020-00199Zimmer BiometRead the record ↗Not graded by the source2020-08-06FDA MAUDEStryker3005985723-2020-00292Mako Robotic-Arm
Mako Robotic-Arm — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: THE PARTIAL KNEE CUTS WERE WAY OFF AND WE HAD TO BAIL TO A TKA. WE HAD COMPLETED THE CASE AND TRIALING WHEN THE SURGEON TOOK A CLOSER LOOK AND DID NOT LIKE THE WAY THE IMPLANTS WERE POSITIONED. WHAT IT LOOKED LIKE ON THE PLAN WAS NOT WHAT IT LOOKED LIKE ON THE PATIENT. WE HAD NO PROBLEMS WITH ANY CHECK POINTS OR MOVED ARRAYS DURING THE CASE AT ALL BUT THE CUTS WERE OFF CASE TYPE / APPLICATION: PKA (MICS). SURGICAL DELAY<= 15 MINUTES.
cause not established3005985723-2020-00292StrykerRead the record ↗Not graded by the source2020-08-06FDA MAUDEZimmer Biomet3009185973-2020-00198ROSA Robotic Surgery
ROSA Robotic Surgery — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: THE FOLLOWING EVENT OCCURRED DURING AN SEEG CASE AT (B)(6) HOSPITAL. AFTER FINISHING THE SEEG CASE WHERE THE PATIENT HAD BEEN CONNECTED TO THE ROSA VIA THE MAYFIELD ADAPTOR CLAMPED ONTO THE LEKSELL FRAME, A POST-OP SCAN WAS TAKEN IN THE OPERATING ROOM (WHILE THE PATIENT WAS STILL UNDER ANESTHESIA) UTILIZING AN O-ARM. THE SCAN WAS THEN TRANSFERRED TO THE ROBOT VIA USB AND SUBSEQUENTLY MERGED TO AN MRI SCAN, WHICH WAS USED FOR INITIAL PLANNING. THE SURGEON VERIFIED THE MERGE AND THEN COMPARED THE SCAN TO THE PLAN. THE SURGEON NOTED THAT THE ELECTRODES DEVIATED ANTERIORLY FROM THE PLANNED TRAJECTORIES (THIS DEVIATION WAS NOTICED ON EACH TRAJECTORY ENTRY AND TARGET). THE SURGEON DID NOT EXPRESS NEED FOR A REVISION AND DID NOT ADJUST PLACEMENT OF ANY ELECTRODES. HOWEVER, THE SURGEON COMMENTED THEIR COULD BE A MERGE ISSUE, ALTHOUGH HE DID NOT PERSONALLY RECOGNIZE ONE, WHEN AT THE STEP THAT ASKED TO VERIFY THE 3D MERGE. THE FIELD SERVICE ENGINEER, ONCE THE PATIENT WAS DISCONNECTED LOOKED AT THE MERGE BETWEEN THE PRE-OP O ARM SPIN USED FOR REGISTRATION AND THE POST-OP SCAN TO SEE IF THERE WAS AN ISSUE THAT COULD BE IDENTIFIED WITH THE MERGE. WHEN COMPARING THE FIDUCIALS FROM PRE-OP TO POST
cause not established3009185973-2020-00198Zimmer BiometRead the record ↗Not graded by the source2020-08-05FDA MAUDEStryker3005985723-2020-00287Mako Robotic-Arm
Mako Robotic-Arm — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: IT WAS REPORTED THAT THE PATIENT'S LEFT KNEE WAS REVISED DUE TO LOOSENING OF THE FEMORAL COMPONENT. SURGEON REPORTED THAT THE DISTAL FEMUR METAPHYSIS LOOKED "DISINTEGRATED." PATIENT'S KNEE CONSTRUCT WAS REVISED TO A HINGED DISTAL FEMUR CONSTRUCT. REP CONFIRMED THERE ARE NO ALLEGATIONS AGAINST THE REVISED TIBIAL BASEPLATE OR INSERT. REP PROVIDED PRIMARY AND REVISION USAGE SHEETS, PRE- AND POST-REVISION X-RAYS, AND CONFIRMED THAT NO FURTHER INFORMATION WILL BE RELEASED.
cause not established3005985723-2020-00287StrykerRead the record ↗Not graded by the source2020-08-04FDA MAUDEIntuitive Surgical, Inc.da Vinci Surgical System2955842-2022-12288da Vinci Surgical System
da Vinci Surgical System — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: ON (B)(6) 2020, INTUITIVE BECAME AWARE OF A ¿JOURNAL OF GASTROINTESTINAL ONCOLOGY¿ ARTICLE TITLED, ¿RARE POSTOPERATIVE HEMORRHAGE AFTER ROBOTIC-ASSISTED PANCREATODUODENECTOMY FOR PANCREATIC HEAD CANCER: A CASE REPORT¿ (ZHOU, J.J., CHEN, W., ET AL., 2020). WITHIN THE JOURNAL ARTICLE, AN OPERATIVE COMPLICATION INVOLVING A DA VINCI SURGICAL PROCEDURE WAS NOTED. ON POST OPERATIVE DAY 6 PATIENT UNDERWENT AN EMERGENCY OPERATION DUE TO BLOOD IN VOMIT. PATIENT WAS FOUND TO HAVE AN OUTPUT JEJUNAL LOOP INTUSSUSCEPTION IN THE STOMACH. PATIENT WAS DISCHARGED ON POST OPERATIVE DAY 10 AND WAS REPORTED TO BE DOING WELL. INTUITIVE SURGICAL, INC. (ISI) MADE MULTIPLE FOLLOW-UP ATTEMPTS TO OBTAIN ADDITIONAL INFORMATION. HOWEVER, NO FURTHER DETAILS HAVE BEEN RECEIVED AS OF THE DATE OF THIS REPORT.
cause not established2955842-2022-12288Intuitive Surgical, Inc.da Vinci Surgical SystemRead the record ↗Not graded by the source2020-08-04FDA MAUDEZimmer Biomet0009617840-2020-00004ROSA Robotic Surgery
ROSA Robotic Surgery — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: NO ADDITIONAL INFORMATION REPORTED.
cause not established0009617840-2020-00004Zimmer BiometRead the record ↗Not graded by the source2020-08-04FDA MAUDEIntuitive Surgical, Inc.da Vinci Surgical System2955842-2020-10841da Vinci Surgical System
da Vinci Surgical System — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: REFER TO H10/H11 FOR FOLLOW-UP INFORMATION.
cause not established2955842-2020-10841Intuitive Surgical, Inc.da Vinci Surgical SystemRead the record ↗Not graded by the source2020-08-04FDA MAUDEIntuitive Surgical, Inc.da Vinci Surgical System2955842-2023-13163da Vinci Surgical System
da Vinci Surgical System — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: IT WAS REPORTED THAT DURING A DA VINCI-ASSISTED TOTAL BENIGN HYSTERECTOMY SURGICAL PROCEDURE, A SMALL GRAY COVER ON THE END OF THE SYNCHROSEAL INSTRUMENT FELL INTO THE PATIENT. THE PIECE WAS RETRIEVED DURING THE SAME PROCEDURE. THE SURGEON USED A VESSEL SEALER INSTRUMENT TO CONTINUE AND THE PROCEDURE WAS COMPLETED WITH NO REPORT OF PATIENT HARM, INJURY OR ADVERSE OUTCOME. INTUITIVE SURGICAL, INC. (ISI) FOLLOWED UP WITH THE INITIAL REPORTER AND OBTAINED ADDITIONAL INFORMATION: THE INSTRUMENT WAS IN USE FOR 15 MINUTES PRIOR TO THE ISSUE. THE INSTRUMENT WAS INSPECTED PRIOR TO USE AND NO DAMAGE WAS NOTED. PRIOR TO INSTRUMENT USAGE, THE SCRUB TECH WAS ATTEMPTING TO PEEL OFF THE YELLOW PROTECTIVE COVER ON TOP OF THE JAW COVER AND MIGHT HAVE LOOSE THE JAW COVER DURING THE PROCESS. THE SURGEON WAS DISSECTING A TISSUE WHEN A FRAGMENT FROM THE SYNCHROSEAL INSTRUMENT FELL INTO THE PATIENT. THE FRAGMENT WAS RETRIEVED WITH A GRASPER INSTRUMENT. THERE WAS NO INSTRUMENT COLLISION DURING THE PROCEDURE.
cause not established2955842-2023-13163Intuitive Surgical, Inc.da Vinci Surgical SystemRead the record ↗Not graded by the source2020-08-04FDA MAUDEIntuitive Surgical, Inc.da Vinci Surgical System2955842-2020-10871da Vinci Surgical System
da Vinci Surgical System — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: REFER TO H10/H11 FOR FOLLOW-UP INFORMATION.
cause not established2955842-2020-10871Intuitive Surgical, Inc.da Vinci Surgical SystemRead the record ↗Not graded by the source2020-08-03FDA MAUDEAuris HealthMonarch Platform3014447948-2020-00007Monarch Platform
Monarch Platform — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: ON (B)(6) 2020, IT WAS REPORTED THAT AFTER A MONARCH-ASSISTED BRONCHOSCOPY PROCEDURE, THE PATIENT WAS OBSERVED TO HAVE A PNEUMOTHORAX DURING POST-OP CHECK-UP. THE CUSTOMER DOES NOT FEEL THE PNEUMOTHORAX WAS CAUSED BY THE MONARCH PLATFORM. DURING THE CASE, NO AURIS INSTRUMENTS WERE USED. THE INSTRUMENT USED WAS A MEDTRONIC NEEDLE TIPPED CYTOLOGY BRUSH. A CHEST TUBE WAS PLACED TO TREAT THE PNEUMOTHORAX, AND THE PATIENT WAS HOSPITALIZED FOR 2 DAYS. THE PATIENT HAS SINCE RECOVERED AND WAS RELEASED FROM HOSPITAL.
cause not established3014447948-2020-00007Auris HealthMonarch PlatformRead the record ↗Not graded by the source2020-07-28FDA MAUDEZimmer Biomet3009185973-2020-00188ROSA Robotic Surgery
ROSA Robotic Surgery — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: THE FOLLOWING EVENT OCCURRED DURING A DBS CASE ON (B)(6) 2020: FOLLOWING THE IMPLANTATION OF TWO LEADS, UTILIZING THE FHC STARDRIVE FOR A DBS CASE, A POST-OP SCAN WAS TAKEN WHILE THE PATIENT WAS STILL UNDER ANESTHESIA, ALTHOUGH DISCONNECTED FROM THE ROBOT, USING THE BODYTOM. THE SCAN WAS TRANSFERRED AND MERGED TO THE MRI ON THE ROSA ROBOT IN ORDER TO CONFIRM PLACEMENT OF THE LEADS. AFTER CHECKING THAT THE MERGER WAS ACCURATE, IT WAS FOUND THAT WHEN LOOKING AT THE PLANNED TRAJECTORIES, THAT THE RIGHT LEAD WAS 8MM SHALLOW THAN THE PLANNED TARGET (THE ENTRY POINT OF THE RIGHT LEAD WAS COMPLETELY ACCURATE). THERE WAS ALSO NO ACCURACY ISSUES WITH THE LEFT LEAD. AT THIS POINT, THE SURGEON DETERMINED THAT THE RIGHT LEAD WOULD NEED TO BE ADVANCED THE 8 MM ON THE RIGHT SIDE, WHICH WOULD ULTIMATELY REQUIRE THE LEAD TO BE REMOVED AND REPLACED. SURGEON AND THE RESIDENTS THAT WERE PRESENT BELIEVED THAT THE LEAD HAD BEEN RETRACTED SLIGHTLY WHEN THE WATCHFACE HAD BEEN PLACED ON TOP TO SECURE THE LEAD, THUS THAT THE ERROR HAD NOT BEEN DUE TO THE ROBOT, BUT RATHER USER ERROR. THE PLAN WAS NOT ALTERED AND THE PATIENT WAS THEN RECONNECTED TO THE ROSA ROBOT AGAIN USING THE LEKSELL HEADFRAME ADAPTOR. R
cause not established3009185973-2020-00188Zimmer BiometRead the record ↗Not graded by the source2020-07-27FDA MAUDEGlobus MedicalExcelsiusGPS3004142400-2020-00095ExcelsiusGPS
ExcelsiusGPS — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: IT WAS REPORTED THAT THE LEFT L4 SCREW WAS NOT PLACED ACCORDING TO THE SURGICAL PLAN. THE SCREW WAS REMOVED AND REPOSITIONED INTRA-OPERATIVELY.
cause not established3004142400-2020-00095Globus MedicalExcelsiusGPSRead the record ↗Not graded by the source2020-07-27FDA MAUDEStryker3005985723-2021-00005Mako Robotic-Arm
Mako Robotic-Arm — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: AS REPORTED: "PT BROUGHT TO EMERGENCY DEPARTMENT DUE TO LEG SWELLING AFTER A FALL AT HOME. OBVIOUS SHORTENING OF LEG NOTED IN EMERGENCY DEPARTMENT, XRAY SHOWED HIP DISLOCATION AND PT ADMITTED. PT RETURN TO OR (B)(6) 2020 FOR HIP REVISION. PT DISCHARGED TO...REHAB."
cause not established3005985723-2021-00005StrykerRead the record ↗Not graded by the source2020-07-27FDA MAUDEAuris HealthMonarch Platform3014447948-2020-00006Monarch Platform
Monarch Platform — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: ON (B)(6) 2020, A PATIENT EXPERIENCED A PNEUMOTHORAX THAT WAS DISCOVERED THREE HOURS AFTER THE PROCEDURE DURING THE POST-OP CHECKS. THE PNEUMOTHORAX WAS LOCATED IN THE LEFT UPPER LUNG WHERE THE TARGET WAS LOCATED. DURING THE CASE, NO AURIS INSTRUMENTS WERE USED. THE INSTRUMENTS USED DURING THE CASE WERE AN OLYMPUS PERIVIEW 21 GAUGE NEEDLE, AND AN OLYMPUS FORCEPS. THE PATIENT WAS HELD OVERNIGHT FOR OBSERVATION, NO OTHER INTERVENTION WAS REQUIRED. THE PNEUMOTHORAX WAS RESOLVED, AND THE PATIENT WAS RELEASED ON THE FOLLOWING DAY.
cause not established3014447948-2020-00006Auris HealthMonarch PlatformRead the record ↗Not graded by the source2020-07-27FDA MAUDEIntuitive Surgical, Inc.da Vinci Surgical System2955842-2020-10777da Vinci Surgical System
da Vinci Surgical System — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: REFER TO H10/H11 FOR FOLLOW-UP INFORMATION.
cause not established2955842-2020-10777Intuitive Surgical, Inc.da Vinci Surgical SystemRead the record ↗Not graded by the source2020-07-27FDA MAUDEZimmer Biomet3009185973-2020-00195ROSA Robotic Surgery
ROSA Robotic Surgery — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: THE 6MM CANNULA BECAME STUCK INSIDE THE DRILL ADAPTER, WHICH THE SURGEON USED A MALLET TO PASS THE CANNULA THROUGH THE DRILL ADAPTER. THIS RESULTED IN A "SKIVED" TRAJECTORY.
cause not established3009185973-2020-00195Zimmer BiometRead the record ↗Not graded by the source2020-07-24FDA MAUDEZimmer Biomet3009185973-2020-00286ROSA Robotic Surgery
ROSA Robotic Surgery — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: AFTER COMPLETION OF REGISTRATION AND INTRAOPERATIVE IMAGE ACQUISITION FOR THE ROSA SPINE ROBOT, THE SURGEON PLANNED HIS SCREW TRAJECTORIES. ONCE PLANNING WAS COMPLETED, THE CLINICAL REPRESENTATIVE (CR) DROVE TO THE FIRST SCREW. THE SURGEON WAS LOOKING AWAY FROM THE ROBOT WHILE ON THE PEDAL. THE CR WAS TRYING TO WATCH THE ARM MOVEMENT AS WELL SO THAT IT DID NOT RUN INTO THE PATIENT REFERENCE, BUT THE INSTRUMENT HOLDER ENDED UP COLLIDING WITH THE PATIENT REFERENCE. DUE TO THE COLLISION, THE PATIENT REFERENCE DID LOOSEN FROM THE PSIS PIN. BECAUSE OF THIS THE CR INFORMED THE SURGEON THAT ANOTHER INTRAOPERATIVE SCAN WOULD HAVE TO BE PERFORMED. THE SURGEON DECIDED TO ABORT THE CASE USING ROSA AND DECIDED TO PLACE THE PEDICLE SCREWS IN THE TRADITIONAL TECHNIQUE. THE PATIENT WAS NOT INJURED OR EFFECTED DUE TO THE COLLISION.
cause not established3009185973-2020-00286Zimmer BiometRead the record ↗Not graded by the source2020-07-23FDA MAUDEZimmer Biomet3009185973-2020-00189ROSA Robotic Surgery
ROSA Robotic Surgery — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: DURING AN SEEG PROCEDURE THE MAYFIELD HEAD HOLDER ADAPTOR SLOWLY LOOSENED AND THEN EVENTUALLY SLIPPED FROM IT'S POSITION. THIS MOVEMENT CAUSED A SIGNIFICANT HEAD SHIFT AND CAUSED THE SURGERY TO BE DELAYED BY 40+ MINUTES. THIS DELAY WAS BECAUSE THE PATIENT HAD TO BE REPOSITIONED AND RE-REGISTERED FOR SURGERY. AT THE TIME OF THE SHIFT, 5 ELECTRODES HAD BEEN PLACED AND A TOTAL OF 8 WERE GOING TO BE PLACED FOR THE SURGERY. TWO OF THE ELECTRODES WERE REMOVED AFTER THE SHIFT (DUE TO THE MAYFIELD ADAPTOR SLOWLY SHIFTING WHICH WAS NOT REALIZED UNTIL THE ACCURACY OF THE ENTRY SITES OF EACH TRAJECTORY WAS CHECKED). AFTER THE SECOND REGISTRATION, THE PROCEDURE CONTINUED AS PLANNED AND ALL TRAJECTORIES WERE FINISHED TO COMPLETION, INCLUDING THE TWO ELECTRODES THAT HAD PREVIOUSLY REMOVED.
cause not established3009185973-2020-00189Zimmer BiometRead the record ↗Not graded by the source2020-07-23FDA MAUDEIntuitive Surgical, Inc.da Vinci Surgical System2955842-2023-14774da Vinci Surgical System
da Vinci Surgical System — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: IT WAS REPORTED THAT DURING A DA VINCI-ASSISTED HIATAL HERNIA REPAIR SURGICAL PROCEDURE, PART OF THE BLUE SPRING PAD BROKE OFF OF THE SYNCHROSEAL INSTRUMENT JAW. THE PROCEDURE WAS COMPLETED WITH NO REPORTED INJURY. INTUITIVE SURGICAL, INC. (ISI) FOLLOWED UP WITH THE INITIAL REPORTER AND OBTAINED THE FOLLOWING ADDITIONAL INFORMATION: THE SYNCHROSEAL INSTRUMENT WAS INSPECTED PRIOR TO USE AND WILL BE RETURNED TO ISI FOR ANALYSIS. THE BREAKAGE WAS NOTED DURING DISSECTION OF THE TISSUE NEAR THE CRUS. THE BROKEN FRAGMENT DID FALL INTO THE PATIENT AND WAS RETRIEVED AT THE TIME WITH A LAPAROSCOPIC NEEDLE DRIVER INSTRUMENT. THE SURGEON IS UNSURE AS TO WHAT CAUSED THE BREAKAGE. THE BREAKAGE WAS OBSERVED 15 MINUTES INTO USING THE SYNCHROSEAL INSTRUMENT. THE ADDITIONAL INSTRUMENT USED AT THE TIME OF THE PROCEDURE WAS A FENESTRATED BIPOLAR FORCEPS INSTRUMENT. THE SYNCHROSEAL INSTRUMENT DID NOT COLLIDE WITH ANY OTHER INSTRUMENTS DURING THE PROCEDURE, AND THE WRIST WAS STRAIGHTENED PRIOR TO REMOVAL. THE PROCEDURE WAS SUCCESSFULLY COMPLETED ROBOTICALLY WITH NO ADVERSE PATIENT CONSEQUENCES.
cause not established2955842-2023-14774Intuitive Surgical, Inc.da Vinci Surgical SystemRead the record ↗Not graded by the source2020-07-22FDA MAUDEZimmer Biomet3009185973-2020-00187ROSA Robotic Surgery
ROSA Robotic Surgery — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: ON (B)(6) 2020, THE SURGEON NOTIFIED THE CLINICAL REPRESENTATIVE (CR) WHO ASSISTED THE SURGERY, THAT DURING THE POST OP SCAN AND MERGE THERE WAS DEVIATION FROM THE PLANNED ENTRY BY ~5MM. THE SURGEON SAID THERE WAS NO IMPACT TO THE PATIENT, BUT THE READING ON THE RNS DEPTH LEADS WILL BE AFFECTED AS THEY ARE NOT IN THE PLANNED LOCATION. THE PATIENT WAS REGISTERED USING CONTACTLESS REGISTRATION. THE PATIENT WAS WEARING A FACE MASK DURING THE CT SCAN, SO THE METAL BRIDGE OF THE FACE MASK AS WELL AS THE ELASTIC LOOPS OF THE MASK WERE PROMINENT IN THE SCAN. THE VERIFICATION PROCESS LOOKED TO BE WITHIN ACCEPTABLE RANGE AND NO NOTICEABLE SHIFTS IN THE HEAD OCCURRED TO THE CR¿S AND SURGEON¿S KNOWLEDGE.
cause not established3009185973-2020-00187Zimmer BiometRead the record ↗Not graded by the source2020-07-22FDA MAUDEIntuitive Surgical, Inc.da Vinci Surgical System2955842-2020-10941da Vinci Surgical System
da Vinci Surgical System — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: REFER TO H10/H11 FOR FOLLOW-UP INFORMATION.
cause not established2955842-2020-10941Intuitive Surgical, Inc.da Vinci Surgical SystemRead the record ↗Not graded by the source2020-07-21FDA MAUDEIntuitive Surgical, Inc.da Vinci Surgical System2955842-2022-11772da Vinci Surgical System
da Vinci Surgical System — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: ON 21-JUL- 2020, INTUITIVE SURGICAL, INC. (ISI) BECAME AWARE OF A SURGICAL ENDOSCOPY ARTICLE TITLED, ¿ROBOTIC TREATMENT FOR URINARY TRACT ENDOMETRIOSIS: PRELIMINARY RESULTS AND SURGICAL DETAILS IN A HIGH-VOLUME SINGLE-INSTITUTIONAL COHORT STUDY¿ (DIMAIDA, F., MARI,. A., MORESELLI, S., ET AL., 2020). THE AIM OF THE STUDY WAS TO PRESENT THE SURGICAL TECHNIQUES AND THE POSTOPERATIVE OUTCOMES IN WOMEN TREATED WITH ROBOTIC EXCISION FOR DEEP ENDOMETRIOSIS INVOLVING THE URINARY TRACT. THIS STUDY RETROSPECTIVELY REVIEWED THE PROSPECTIVELY RECORDED CLINICAL DATA OF WOMEN CONSECUTIVELY UNDERGOING MINIMALLY INVASIVE TREATMENT FOR COMPLEX ENDOMETRIOSIS INVOLVING URINARY TRACT IN OUR CENTER BETWEEN JANUARY 2012 AND JUNE 2018. A TOTAL OF 74 CONSECUTIVE PATIENTS WERE ENROLLED AND, OF WHICH, 46 WERE TREATED WITH ROBOTIC SURGERY WITH EITHER A DA VINCI SI OR XI DA VINCI SURGICAL SYSTEM. ALL THE PATIENTS RECEIVED A PREOPERATIVE MULTIDISCIPLINARY EVALUATION WITH THE GENERAL SURGEON, THE GYNECOLOGIST, AND THE UROLOGIST DUE TO THE FREQUENT CONCOMITANT INVOLVEMENT OF BOWEL AND GENITAL SYSTEM. PATIENTS UNDERGOING ROBOTIC SURGERY WERE TREATED WITH THE SI OR XI DA VINCI SURGICAL SYSTEM. WITHIN THE JOURNAL A
cause not established2955842-2022-11772Intuitive Surgical, Inc.da Vinci Surgical SystemRead the record ↗Not graded by the source2020-07-21FDA MAUDEIntuitive Surgical, Inc.da Vinci Surgical System2955842-2020-10759da Vinci Surgical System
da Vinci Surgical System — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: IT WAS REPORTED THAT DURING A DA VINCI-ASSISTED LOW ANTERIOR RESECTION SURGICAL PROCEDURE, THE TIP OF THE HARMONIC ACE CURVED SHEARS BROKE AND FELL INSIDE THE PATIENT. THE FRAGMENT WAS RETRIEVED AND A BACKUP INSTRUMENT OF THE SAME KIND WAS INSTALLED TO PROCEED. THE PROCEDURE WAS COMPLETED WITH NO REPORTED INJURY. INTUITIVE SURGICAL, INC. (ISI) FOLLOWED UP WITH THE OPERATING ROOM (OR) NURSE AND OBTAINED THE FOLLOWING ADDITIONAL INFORMATION: ALL FRAGMENTS WERE RETRIEVED DURING THE SAME SURGICAL PROCEDURE. REPORTEDLY, THE TIP WAS NEATLY BROKEN AND IMMEDIATELY REMOVED FROM THE PATIENT'S BODY. THE INSTRUMENT WAS INSPECTED PRIOR TO USE. THE SURGEON WAS DISSECTING TISSUE WHEN THE DEVICE FRAGMENT FELL INSIDE THE PATIENT. THE SURGEON DID NOT NOTICE ANY ISSUES WITH THE FUNCTIONALITY OF THE INSTRUMENT DURING THE SURGICAL PROCEDURE AND THE INSTRUMENT DID NOT COLLIDE WITH ANY OTHER INSTRUMENTS OR OTHER HARD MATERIALS. THE INSTRUMENT WAS NEVER REMOVED PRIOR TO THE BREAKAGE. UPON THE FINAL REMOVAL OF THE INSTRUMENT, THE WRIST WAS STRAIGHTENED AND THE SURGICAL STAFF DID NOT FEEL ANY RESISTANCE UPON REMOVAL OF THE INSTRUMENT THROUGH THE CANNULA. THE SURGICAL STAFF DID NOT NOTICE ANY DAMAGE TO THE C
cause not established2955842-2020-10759Intuitive Surgical, Inc.da Vinci Surgical SystemRead the record ↗Not graded by the source2020-07-20FDA MAUDEIntuitive Surgical, Inc.da Vinci Surgical System2955842-2020-10662da Vinci Surgical System
da Vinci Surgical System — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: REFER TO H10/H11 FOR FOLLOW-UP INFORMATION.
cause not established2955842-2020-10662Intuitive Surgical, Inc.da Vinci Surgical SystemRead the record ↗Not graded by the source2020-07-20FDA MAUDEIntuitive Surgical, Inc.da Vinci Surgical System2955842-2020-10795da Vinci Surgical System
da Vinci Surgical System — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: REFER TO H10/H11 FOR FOLLOW-UP INFORMATION.
cause not established2955842-2020-10795Intuitive Surgical, Inc.da Vinci Surgical SystemRead the record ↗Not graded by the source2020-07-17FDA MAUDEIntuitive Surgical, Inc.da Vinci Surgical System2955842-2020-10790da Vinci Surgical System
da Vinci Surgical System — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: REFER TO H10/H11 FOR FOLLOW-UP INFORMATION.
cause not established2955842-2020-10790Intuitive Surgical, Inc.da Vinci Surgical SystemRead the record ↗Not graded by the source2020-07-17FDA MAUDEGlobus MedicalExcelsiusGPS3004142400-2020-00097ExcelsiusGPS
ExcelsiusGPS — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: IT WAS REPORTED THAT A SCREW PLACED AT L5 WAS NOT PLACED ACCORDING TO THE SURGICAL PLAN. THE MISPLACED SCREW WAS REMOVED.
cause not established3004142400-2020-00097Globus MedicalExcelsiusGPSRead the record ↗Not graded by the source2020-07-16FDA MAUDEIntuitive Surgical, Inc.da Vinci Surgical System2955842-2020-10996da Vinci Surgical System
da Vinci Surgical System — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: REFER TO H10/H11 FOR FOLLOW-UP INFORMATION.
cause not established2955842-2020-10996Intuitive Surgical, Inc.da Vinci Surgical SystemRead the record ↗Not graded by the source2020-07-16FDA MAUDEStryker3005985723-2020-00246Mako Robotic-Arm
Mako Robotic-Arm — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: AFTER CASE SURGEON SENT ME A POST OP X-RAY THAT SHOWED A ANTERIOR FEMORAL NOTCH. NO SURGICAL DELAY. CASE TYPE: TKA.
cause not established3005985723-2020-00246StrykerRead the record ↗Not graded by the source2020-07-14FDA MAUDEGlobus MedicalExcelsiusGPS3004142400-2020-00088ExcelsiusGPS
ExcelsiusGPS — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: IT WAS REPORTED THAT THE RIGHT L4 SCREW WAS NOT PLACED ACCORDING TO PLAN. THE SCREW WAS REMOVED AND REPLACED IN THE PROPER POSITION.
cause not established3004142400-2020-00088Globus MedicalExcelsiusGPSRead the record ↗Not graded by the source2020-07-14FDA MAUDEZimmer Biomet3009185973-2020-00171ROSA Robotic Surgery
ROSA Robotic Surgery — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: ON THE MORNING OF (B)(6) 2020, THE SURGEON WAS USING ROSA TO IMPLANT A RNS DEVICE. DURING THE FIRST ATTEMPT OF REGISTRATION THE ROBOT HAD A 'UNRECOVERABLE ERROR' AND SHUTDOWN. THIS WAS AFTER THE INITIAL REGISTRATION POINTS WERE PLACED AND TWO OF THE POINTS HAD BEEN ADJUSTED FOR ACCURACY. THE ARM MOVED TO THE INTERMEDIATE POSITION AND THEN WAS ABOUT TO START THE AUTOMATIC SCAN OF THE PATIENT'S FOREHEAD WHEN IT SHUTDOWN. THE ROBOT WAS REBOOTED AND THE REGISTRATION PROCESS WAS STARTED AGAIN. DURING THE MATCHING OF THE INITIAL REGISTRATION POINTS, THE ROBOTIC ARM BEGAN TO MAKE A GRINDING NOISE AT THE 2ND JOINT FROM THE BASE. THIS SOUND WAS NOT A HUMMING NOISE, BUT A MECHANICAL GRINDING NOISE. THE ARM WAS IN POSITION TO COLLECT THE DATA POINT FROM THE LEFT LATERAL CANTHUS AND THE ARM WAS NOT BEING MOVED WITH EXCESSIVE FORCE. THE MOVEMENT OF THE ARM COULD BE DESCRIBED AS NORMAL. THE SURGEON NOTICED THE SOUND/FEEDBACK FROM THE ARM AND ALERTED THE COMPANY FIELD SERVICE ENGINEER. ROUGHLY, 5 SECONDS PASSED AND THE ROBOT HAD THE SAME ERROR IT HAD BEFORE. RESTARTED THE ROBOT AND TRIED TO CONNECT TO THE CONTROLLER AND CONTINUE WITH THE SURGERY, BUT THE ROBOT WOULD NOT CONNECT. THE USE OF ROSA F
cause not established3009185973-2020-00171Zimmer BiometRead the record ↗Not graded by the source2020-07-13FDA MAUDEIntuitive Surgical, Inc.da Vinci Surgical System2955842-2020-10774da Vinci Surgical System
da Vinci Surgical System — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: REFER TO H10/H11 FOR FOLLOW-UP INFORMATION.
cause not established2955842-2020-10774Intuitive Surgical, Inc.da Vinci Surgical SystemRead the record ↗Not graded by the source2020-07-13FDA MAUDEIntuitive Surgical, Inc.da Vinci Surgical System2955842-2020-10736da Vinci Surgical System
da Vinci Surgical System — Injury report filed with FDA (MAUDE). A MAUDE report does not establish that the device caused the outcome. Reported narrative: REFER TO H10/H11 FOR FOLLOW-UP INFORMATION.
cause not established2955842-2020-10736Intuitive Surgical, Inc.da Vinci Surgical SystemRead the record ↗