BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    PENTAX

    MDR report key: 15749906 · Received November 7, 2022

    Report

    Report Number
    9610877-2022-59686
    Event Type
    Malfunction
    Date Received
    November 7, 2022
    Date of Event
    October 18, 2022
    Report Date
    November 8, 2022
    Manufacturer
    HOYA CORPORATION PENTAX TOKYO OFFICE
    Product Code
    EOB
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    UT, US
    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 VNL-1570STK IS AVAILABLE IN THE USA WITH A 510K NUMBER K162151. WE CHECKED THE RETURNED UNIT AND CONFIRMED THAT THE CCD MODULE BLACKOUT. 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 U/D KNOB BROKEN, THE LIGHT GUIDE CABLE FOR CONTROL BODY BROKEN, THE REMOTE CONTROL BUTTONS PERFORATED, THE LIGHT GUIDE CABLE BUCKLED, THE ELECTRICAL CONNECTOR CORRODED, THE REMOTE CONTROL BUTTONS LEAK, THE REMOTE CONTROL BUTTONS CUT, AND THE REMOTE CONTROL BUTTONS MISCONFIGURED; HOWEVER, THEY ARE NOT THE MAIN CAUSE, AND/OR IRRELEVANT TO THE ALLEGED COMPLAINT. BASED ON THE TECHNICAL REPORT "HR-RPT-0586(IMAGE FAILURE)" 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(BLACKOUT).

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    2377365 PENTAX VIDEO NASO PHARYNGO LARYNGOSTROBOSCOPE EOB HOYA CORPORATION PENTAX TOKYO OFFICE VNL-1070STK

    Patients

    Seq Age Sex Outcome Treatment
    1 Unknown