FDA Adverse Event Malfunction Summary report: N

BRAVO

MDR report key: 3102596 · Received May 1, 2013

Report

Report Number: 9710107-2013-00120
Event Type: Malfunction
Date Received: May 1, 2013
Report Date: April 19, 2013
Manufacturer: GIVEN IMAGING LTD.
Product Code: FFT
PMA / PMN Number: K002028
Product Problem: Yes
Report Source: Manufacturer report
Reporter Location: WA, US
Reporter Occupation: OTHER

Narratives

Additional Manufacturer Narrative · 1

(B)(4). EVALUATION SUMMARY: ONE DELIVERY SYSTEM AND CAPSULE WERE RETURNED TO MEDTRONIC FOR EVALUATION. THE DELIVERY SYSTEM WAS INVESTIGATED VISUALLY FOR EXTERNAL DAMAGE. THE TROCAR NEEDLE WAS ADVANCED. THERE WERE NO SIGNS OF BLOOD OR TISSUE ON THE DEVICE. THE DELIVERY SYSTEM WAS NOT BENT AND THE PLUNGER WAS NOT BROKEN. THE EMERGENCY RELEASE ON THE DELIVERY SYSTEM WAS NOT IMPLEMENTED. THE CAPSULE ELECTRODES WERE VISUALLY ACCEPTABLE. THE WIRE THAT HOLDS THE CAPSULE WAS COMPLETELY NOT OFF AND THE FOAM GASKET WAS IN GOOD CONDITION. THE DELIVERY SYSTEM DID NOT HAVE ANY VISIBLE DAMAGE. AS THE PRODUCT WAS RECEIVED, THE DEVICE FUNCTIONED PER SPECIFICATION. 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.

Description of Event or Problem · 1

A REPEAT PROCEDURE WAS NECESSARY DUE TO THE ALLEGED DEVICE MALFUNCTION. INTERVENTION WAS NOT REQUIRED. THERE WAS EXTRA SALIVA THAT MADE HAVE LED TO THE EVENT. AN ENDOSCOPY WAS PERFORMED PRIOR TO THE PROCEDURE AND THE ESOPHAGUS APPEARED TO BE NORMAL.

Devices

Seq	Brand	Generic	Product Code	Manufacturer	Model	Lot	UDI-DI
189969	BRAVO	BRAVO PH CAPSULE	FFT	GIVEN IMAGING LTD.	FGS-0313	20658Q

Patients

Seq	Age	Sex	Outcome	Treatment
1			Required Intervention