BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    PENTAX

    MDR report key: 13312542 · Received January 21, 2022

    Report

    Report Number
    9610877-2022-50131
    Event Type
    Malfunction
    Date Received
    January 21, 2022
    Date of Event
    January 12, 2022
    Report Date
    January 21, 2022
    Manufacturer
    HOYA CORPORATION PENTAX TOKYO OFFICE
    Product Code
    FAJ
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CA
    Reporter Occupation
    PHYSICIAN
    Health Professional
    Yes

    Narratives

    Additional Manufacturer Narrative · 0

    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 THE CCD MODULE INTERMITTENT. BASED ON THE RESULT, WE CONCLUDED THAT IT WAS CAUSED DUE TO THE EXCESSIVE FORCE APPLIED ON THE CCD MODULE. 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.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    807215 PENTAX VIDEO CYSTOSCOPE 2.0C 5.5TP 400L FAJ HOYA CORPORATION PENTAX TOKYO OFFICE ECY-1575K

    Patients

    Seq Age Sex Outcome Treatment
    1 Unknown