BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    BRAVO

    MDR report key: 3030859 · Received March 28, 2013

    Report

    Report Number
    9710107-2013-00092
    Event Type
    Malfunction
    Date Received
    March 28, 2013
    Report Date
    March 28, 2013
    Manufacturer
    GIVEN IMAGING LTD.
    Product Code
    FFT
    PMA / PMN Number
    K002028
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CA, US
    Reporter Occupation
    OTHER

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4). THE DEVICE WAS RETURNED TO MEDTRONIC FOR INVESTIGATION. DUE TO THE REPORTED CONDITION AND THE LOT NUMBER OF THE REPORTED AND RETURNED DEVICE, AN INVESTIGATION WAS NOT PERFORMED AS IT IS ADDRESSED IN CORRECTIVE ACTION PREVENTATIVE ACTION (CAPA)# (B)(4). THE CAPA WAS OPENED TO ADDRESS THE TROCAR PIN/NEEDLE OF THE DELIVERY SYSTEM NOT BEING DEPLOYED AS DESIGNED, WHICH RESULTED TO THE FAILURE OF BRAVO CAPSULE ATTACHING TO THE ESOPHAGEAL MUCOSA. THE CAPA WAS DEEMED EFFECTIVE ON NOVEMBER 22, 2012. THIS SUPPLEMENTAL MDR IS BEING FILED LATE AS PART OF A REMEDIATION EFFORT UNDER CAPA (B)(4). THERE WAS NO REQUIRED INTERVENTION TO PREVENT PERMANENT IMPAIRMENT/DAMAGE IN THIS CASE. THE INFORMATION WAS UPDATED IN THIS SUPPLEMENTAL.

    Description of Event or Problem · 1

    CUSTOMER REPORTED ON A BRAVO PH CAPSULE THAT FAILED TO ATTACH. THE PT WAS NOT INJURED FOLLOWING THE PROCEDURE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    128708 BRAVO BRAVO PH CAPSULE FFT GIVEN IMAGING LTD. FGS-0313 20320Q

    Patients

    Seq Age Sex Outcome Treatment
    1 Required Intervention