BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    PENTAX

    MDR report key: 12687244 · Received October 25, 2021

    Report

    Report Number
    9610877-2021-50135
    Event Type
    Malfunction
    Date Received
    October 25, 2021
    Date of Event
    October 14, 2021
    Report Date
    October 25, 2021
    Manufacturer
    HOYA CORPORATION PENTAX TOKYO OFFICE
    Product Code
    FAJ
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    NL
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 1

    THIS DEVICE IS CLASSIFIED AS IMPORT FOR EXPORT, THEREFORE 510K IS NOT APPLICABLE. MODEL EB-1575K IS AVAILABLE IN THE USA WITH A 510K NUMBER K131028. WE CHECKED THE RETURNED UNIT AND CONFIRMED THAT THE CCD DRIVER PCB MALFUNCTION. BASED ON THE RESULT, WE CONCLUDED THAT IT WAS CAUSED DUE TO THE EXCESSIVE FORCE APPLIED ON THE CCD DRIVER PCB; HOWEVER, OTHER FAILURE IS NOT RELATED TO THE ALLEGED COMPLAINT. BASED ON THE TECHNICAL REPORT, IT WAS EVALUATED TO SUBMIT MDR.

    Description of Event or Problem · 1

    THE TIME OF EVENT IS UNKNOWN. THERE WAS NO REPORT OF PATIENT HARM. VIDEO IMAGE FAILURE

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1591422 PENTAX VIDEO CYSTOSCOPE 2.0C 5.5TP 400L FAJ HOYA CORPORATION PENTAX TOKYO OFFICE ECY-1575K

    Patients

    Seq Age Sex Outcome Treatment
    1