BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    PENTAX

    MDR report key: 13797498 · Received March 17, 2022

    Report

    Report Number
    9610877-2022-51799
    Event Type
    Malfunction
    Date Received
    March 17, 2022
    Date of Event
    February 25, 2022
    Report Date
    March 17, 2022
    Manufacturer
    HOYA CORPORATION PENTAX TOKYO OFFICE
    Product Code
    FDF
    UDI-DI
    04961333234066
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    GM
    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 IS AVAILABLE IN THE USA WITH A 510K NUMBER K999999. WE CHECKED THE RETURNED UNIT AND CONFIRMED THAT THE CCD MODULE AS DEFECTIVE. BASED ON THE RESULT, WE CONCLUDED THAT IT WAS CAUSED DUE TO THE EXCESSIVE FORCE APPLIED ON THE CCD MODULE. IN ADDITION, WE CONFIRMED THAT THE LIGHT GUIDE FIBER BUNDLE (LCB) BROKEN, THE OPERATION CHANNEL BUCKLED, THE LIGHT GUIDE CABLE BUCKLED, THE SUCTION CHANNEL BUCKLED, THE REMOTE CONTROL BUTTONS CUT, THE R/L PULLEY WIRE WORN OUT, THE ANGLE WIRE RUPTURE, AND THE U/D PULLEY WIRE RUPTURE; HOWEVER, THEY ARE NOT THE MAIN CAUSE, AND/OR IRRELEVANT TO THE ALLEGED COMPLAINT. 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
    39032 PENTAX VIDEO COLONOSCOPE FDF HOYA CORPORATION PENTAX TOKYO OFFICE EC34-I10TL 04961333234066

    Patients

    Seq Age Sex Outcome Treatment
    1 Unknown