FDA Adverse Event Malfunction Summary report: N

GALAXY SYSTEM

MDR report key: 21428239 · Received February 20, 2025

Report

Report Number
3021325287-2025-00010
Event Type
Malfunction
Date Received
February 20, 2025
Date of Event
January 24, 2025
Report Date
April 17, 2025
Manufacturer
NOAH MEDICAL CORP.
Product Code
EOQ
UDI-DI
00850048825048
PMA / PMN Number
K223144
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
CA, US
Reporter Occupation
003

Narratives

Additional Manufacturer Narrative · 0

SYSTEM MANUFACTURING RECORDS WERE REVIEWED AND FOUND NO ISSUES ASSOCIATED WITH THIS CASE. SCOPE MANUFACTURING RECORDS WERE REVIEWED AND FOUND NO ISSUES ASSOCIATED WITH THIS CASE. PRELIMINARY INVESTIGATIONS REVEALED THAT THE BEHAVIOR OF THE E-STOP LED REMAINING ILLUMINATED AFTER AC POWER IS REMOVED FROM THE SYSTEM INPUT INDICATES THAT THE UPS IS CONTINUING TO POWER ITS AC OUTPUTS FROM ITS BATTERY. THE POTENTIAL IMPACT ON SUBSEQUENT CASES AFTER DELAYED SHUT DOWN WILL RESULT IN THE UPS NOT CHARGING SUFFICIENTLY TO SUPPORT THE FOLLOWING CASES IN THE EVENT OF A POWER FAILURE. NO OTHER MALFUNCTIONS WERE REPORTED. THIS MALFUNCTION IS BEING REPORTED DUE TO THE FOLLOWING CONCLUSIONS: DURING A GALAXY-ASSISTED BIOPSY PROCEDURE, THE USER EXPERIENCED THE SYSTEM NOT BEING ABLE TO SHUT DOWN. INVESTIGATION FINDINGS REVEALED THAT THIS FAILURE INCREASED THE PROBABILITY OF A SEVERE INJURY FROM A FREQUENCY FROM 2 (REMOTE) - 4 (PROBABLE). NO INJURIES OR TREATMENT WERE REPORTED IN THIS CASE. UPDATE H11: INITIAL PRELIMINARY INVESTIGATION FINDINGS SUGGEST THAT THE MALFUNCTION OF THE UPS MAY INCREASE THE LIKELIHOOD OF SEVERE INJURY (BLEEDING, MAJOR) FROM A FREQUENCY OF 2 (REMOTE) TO 4 (PROBABLE). HOWEVER, FOLLOWING A FURTHER RISK ASSESSMENT REVIEW, IT HAS BEEN DETERMINED THAT THE MOST LIKELY RISK ASSOCIATED WITH UPS ISSUES IS AN ABORTED PROCEDURE, WITH A PROBABILITY OF 3 (OCCASIONAL). WHILE THE SEVERITY OF THE INITIAL RISK OF BLEEDING, MAJOR REMAINS AT 3 (SERIOUS), THE PROBABILITY HAS BEEN REASSESSED TO 1 (IMPROBABLE). THEREFORE, THE COMPLAINT IS DEEMED NON-REPORTABLE.

Additional Manufacturer Narrative · 0

SYSTEM MANUFACTURING RECORDS WERE REVIEWED AND FOUND NO ISSUES ASSOCIATED WITH THIS CASE. SCOPE MANUFACTURING RECORDS WERE REVIEWED AND FOUND NO ISSUES ASSOCIATED WITH THIS CASE. PRELIMINARY INVESTIGATIONS REVEALED THAT THE BEHAVIOR OF THE E-STOP LED REMAINING ILLUMINATED AFTER AC POWER IS REMOVED FROM THE SYSTEM INPUT INDICATES THAT THE UPS IS CONTINUING TO POWER ITS AC OUTPUTS FROM ITS BATTERY. THE POTENTIAL IMPACT ON SUBSEQUENT CASES AFTER DELAYED SHUT DOWN WILL RESULT IN THE UPS NOT CHARGING SUFFICIENTLY TO SUPPORT THE FOLLOWING CASES IN THE EVENT OF A POWER FAILURE. NO OTHER MALFUNCTIONS WERE REPORTED. THIS MALFUNCTION IS BEING REPORTED DUE TO THE FOLLOWING CONCLUSIONS: DURING A GALAXY-ASSISTED BIOPSY PROCEDURE, THE USER EXPERIENCED THE SYSTEM NOT BEING ABLE TO SHUT DOWN. INVESTIGATION FINDINGS REVEALED THAT THIS FAILURE INCREASED THE PROBABILITY OF A SEVERE INJURY FROM A FREQUENCY FROM 2 (REMOTE) - 4 (PROBABLE). NO INJURIES OR TREATMENT WERE REPORTED IN THIS CASE.

Description of Event or Problem · 0

IT WAS REPORTED THAT AFTER A GALAXY-ASSISTED BIOPSY PROCEDURE, THE GALAXY SYSTEM DID NOT FULLY SHUT DOWN. THE SYSTEM WAS ABLE TO SHUT DOWN AFTER 15 MINUTES. THERE WERE NO INJURIES REPORTED OR TREATMENT ADMINISTERED WITH THIS CASE. NO OTHER MALFUNCTIONS WERE REPORTED.ALTHOUGH THERE WERE NO INJURIES REPORTED, THIS MALFUNCTION MAY CONTRIBUTE TO A SERIOUS INJURY.

Description of Event or Problem · 0

IT WAS REPORTED THAT AFTER A GALAXY-ASSISTED BIOPSY PROCEDURE, THE GALAXY SYSTEM DID NOT FULLY SHUT DOWN. THE SYSTEM WAS ABLE TO SHUT DOWN AFTER 15 MINUTES. THERE WERE NO INJURIES REPORTED OR TREATMENT ADMINISTERED WITH THIS CASE. NO OTHER MALFUNCTIONS WERE REPORTED. ALTHOUGH THERE WERE NO INJURIES REPORTED, THIS MALFUNCTION MAY CONTRIBUTE TO A SERIOUS INJURY.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1472373 GALAXY SYSTEM GALAXY SYSTEM EOQ NOAH MEDICAL CORP. 00850048825048

Patients

Seq Age Sex Outcome Treatment
1 69 YR Male