BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    PENTAX

    MDR report key: 12678765 · Received October 22, 2021

    Report

    Report Number
    9610877-2021-50122
    Event Type
    Malfunction
    Date Received
    October 22, 2021
    Date of Event
    October 12, 2021
    Report Date
    October 22, 2021
    Manufacturer
    HOYA CORPORATION PENTAX TOKYO OFFICE
    Product Code
    EOQ
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    JA
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 0

    THIS DEVICE IS CLASSIFIED AS IMPORT FOR EXPORT, THEREFORE 510K IS NOT APPLICABLE. MODEL FB-15V IS AVAILABLE IN THE USA WITH A 510K NUMBER K951199. WE CHECKED THE RETURNED UNIT AND CONFIRMED THAT THE CFB IMAGE FAILURE. BASED ON THE RESULT, WE CONCLUDED THAT IT WAS CAUSED DUE TO AN EXCESSIVE FORCE APPLIED ON THE CFB. IN ADDITION, WE CONFIRMED THAT INSERTION FLEXIBLE TUBE CRASHED. BASED ON THE TECHNICAL REPORT, IT WAS EVALUATED TO SUBMIT MDR."

    Description of Event or Problem · 0

    THE TIME OF EVENT IS UNKNOWN. THERE WAS NO REPORT OF PATIENT HARM. FIBER IMAGE FAILURE (BROKEN).

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1581611 PENTAX FIBEROPTICBRONCHOSCOPE 2.0C 4.8TP RO PLS EOQ HOYA CORPORATION PENTAX TOKYO OFFICE FB-15RBS

    Patients

    Seq Age Sex Outcome Treatment
    1