BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    PENTAX

    MDR report key: 12825994 · Received November 17, 2021

    Report

    Report Number
    9610877-2021-50388
    Event Type
    Malfunction
    Date Received
    November 17, 2021
    Date of Event
    November 5, 2021
    Report Date
    November 17, 2021
    Manufacturer
    HOYA CORPORATION PENTAX TOKYO OFFICE
    Product Code
    FDF
    PMA / PMN Number
    K131855
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CA
    Reporter Occupation
    PHYSICIAN
    Health Professional
    Yes

    Narratives

    Additional Manufacturer Narrative · 0

    WE CHECKED THE RETURNED UNIT AND CONFIRMED THAT THE OBJECTIVE PRISM FLUID DAMAGE. BASED ON THE RESULT, WE CONCLUDED THAT IT WAS CAUSED DUE TO THE FLUID DAMAGE FROM THE OBJECTIVE PRISM. BASED ON THE TECHNICAL REPORT AND/OR THE RISK ANALYSIS RESULTS, 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. VIDEO IMAGE FAILURE(STAIN).

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1728143 PENTAX HDVIDEO COLONOSCOPE 3.8C 13.2T 1700L FWJ FDF HOYA CORPORATION PENTAX TOKYO OFFICE EC-3890LI

    Patients

    Seq Age Sex Outcome Treatment
    1 Unknown