FDA Adverse Event Injury Summary report: N

PENTAX

MDR report key: 12072884 · Received June 26, 2021

Report

Report Number
2518897-2021-00143
Event Type
Injury
Date Received
June 26, 2021
Report Date
May 28, 2021
Manufacturer
HOYA CORPORATION PENTAX TOKYO OFFICE
Product Code
EOB
Adverse Event
Yes
Report Source
Distributor report
Reporter Location
NJ, US
Reporter Occupation
OTHER

Narratives

Description of Event or Problem · 1

PENTAX MEDICAL WAS MADE AWARE OF AN ADVERSE EVENT ON (B)(6) 2021 THAT OCCURRED IN THE UNITED STATES. THE REPORTED COMPLAINT WAS THAT THE IT WAS RECENTLY DETERMINED BY HIS HEALTHCARE TEAM THAT HE HAS/HAD AN ALLERGIC REACTION TO THEIR REPROCESSING AGENT. THE ENDOSCOPE MODEL AND SERIAL NUMBER WERE NOT PROVIDED, SO A DEVICE HISTORY REVIEW COULD NOT BE COMPLETED. ADDITIONAL INFORMATION WAS REQUESTED ON 25-JUN-2021 VIA PHONE, BUT THE FACILITY PREFERRED NOT TO PROVIDE ANY ADDITIONAL INFORMATION VERBALLY. A WRITTEN REQUEST VIA EMAIL WAS ALSO SENT, BUT THE RESPONSE HAS NOT BEEN PROVIDED. ALTHOUGH THE PRODUCT CODE HAS NOT BEEN ESTABLISHED AS THE PRODUCT MODEL REMAINS UNKNOWN, PRODUCT CODE EOB IS BEING SELECTED TO SUBMIT THE MDR AND WILL BE UPDATED ON A FOLLOW UP SUPPLEMENTAL REPORT ONCE THE ADDITIONAL INFORMATION IS RECEIVED. THE INVESTIGATION IS IN-PROCESS.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
969502 PENTAX FIBER NASO PHARYNGO LARYNGOSCOPE EOB HOYA CORPORATION PENTAX TOKYO OFFICE UNKNOWN

Patients

Seq Age Sex Outcome Treatment
1 Other