BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    O-ARM 1000 IMAGING SYSTEM

    MDR report key: 6077743 · Received November 3, 2016

    Report

    Report Number
    1723170-2016-04755
    Event Type
    Malfunction
    Date Received
    November 3, 2016
    Date of Event
    March 25, 2015
    Report Date
    November 3, 2016
    Manufacturer
    MEDTRONIC NAVIGATION, INC. (LITTLETON)
    Product Code
    OXO
    PMA / PMN Number
    K050996
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    DE, US
    Reporter Occupation
    BIOMEDICAL ENGINEER

    Narratives

    Additional Manufacturer Narrative · 1

    NO PATIENT INFORMATION PROVIDED AS NO PATIENT WAS INVOLVED IN THIS CONCERN. A SITE REPRESENTATIVE REPORTED THAT WHEN POWERING ON THE IMAGE ACQUISITION SYSTEM (IAS) IT BECAME UNRESPONSIVE IN STAND ALONE MODE. ISSUE NOT DISCOVERED CLINICALLY. HE STATED THAT THERE WAS NO LIGHTS LIT ON THE MOBILE VIEW STATION (MVS) COMPUTER WHERE THE IAS COMPUTER CONNECTS TO. WHEN THEY BYPASSED THIS CONNECTION THEY WERE ABLE TO BOOT THE SYSTEM UP SUCCESSFULLY. THERE WAS NO PATIENT PRESENT WHEN THIS ISSUE WAS IDENTIFIED. NO ONSITE INVESTIGATION BY MEDTRONIC WAS PROVIDED FOR THIS CASE AS THE REPORTER WAS A TRAINED AND AUTHORIZED BIOMEDICAL ENGINEER, HE INVESTIGATED THE PROBLEM AND FOUND THAT THE MOBILE VIEW STATION (MVS) UMBILICAL CABLE WAS CAUSING THE ISSUE. A REPLACEMENT CABLE WAS SHIPPED TO THE SITE. THE SITE THEN REPORTED THAT THE NEW UMBILICAL CABLE RESOLVED THE ISSUE. NO FURTHER ISSUES WERE REPORTED. UPON ANALYSIS OF THE RETURNED CABLE, THE ELECTRICAL DAMAGE TO THE CABLE WAS CONFIRMED AS IT FAILED BENCH TESTING, ALSO, THE CABLE INSULATION EXHIBITED YELLOW DISCOLORATION. A SUBSEQUENT FULL IMAGING SYSTEM CHECK-OUT WAS COMPLETED (NOT SPECIFIC TO THIS EVENT) AND ALL TESTS PASSED. FULL SYSTEM FUNCTIONALITY WAS CONFIRMED. THIS EVENT WAS IDENTIFIED DURING A RETROSPECTIVE REVIEW AS DISCUSSED WITH THE FDA (B)(4) DISTRICT OFFICE ON APRIL 7, 2016 VIA MEDTRONIC NAVIGATION, INC. RESPONSE TO 3/17/2016 FDA-483 FEI: 3004785967. THIS REVIEW WAS PERFORMED AS A RESULT OF RECENT CHANGES/IMPROVEMENTS TO THE MEDTRONIC NAVIGATION, INC. MEDICAL DEVICE REPORT (MDR) REVIEW PROCESS AND IS FOR NON-ADVERSE EVENT REPORTABLE MALFUNCTIONS WITHIN THE LAST TWO YEARS WHERE THE REPORTED MALFUNCTION WAS NOT PREVIOUSLY ASSOCIATED WITH SERIOUS INJURIES. SIMILAR MALFUNCTIONS THAT HAD RESULTED IN SIGNIFICANT DELAYS OF SURGERY OR REQUIRED ADDITIONAL INTERVENTION HAD BEEN REPORTED AS MDR SERIOUS INJURIES. BASED ON THIS 483 OBSERVATION, THE REPORTING DETERMINATION HAS BEEN REVISED TO CONSIDER THESE MALFUNCTION EVENTS REPORTABLE. THIS PROCESS CHANGE RESULTED IN AN OVERALL INCREASE IN THE NUMBER OF MDRS FILED BY MEDTRONIC NAVIGATION, INC., SINCE APRIL 2016. IT SHOULD BE NOTED THAT THIS INCREASE IS NOT THE RESULT OF THE DISCOVERY OF NEW PRODUCT PROBLEMS, BUT RATHER THE RESULT OF A BROADER INTERPRETATION AND APPLICATION OF THE REGULATIONS WITHIN OUR PROCESSES.

    Description of Event or Problem · 1

    A SITE REPRESENTATIVE REPORTED THAT WHEN POWERING ON THE IMAGE ACQUISITION SYSTEM (IAS) IT BECAME UNRESPONSIVE IN STAND ALONE MODE. ISSUE NOT DISCOVERED CLINICALLY. HE STATED THAT THERE WAS NO LIGHTS LIT ON THE MOBILE VIEW STATION (MVS) COMPUTER WHERE THE IAS COMPUTER CONNECTS TO. WHEN THEY BYPASSED THIS CONNECTION THEY WERE ABLE TO BOOT THE SYSTEM UP SUCCESSFULLY. THERE WAS NO PATIENT PRESENT WHEN THIS ISSUE WAS IDENTIFIED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    726563 O-ARM 1000 IMAGING SYSTEM IMAGE-INTENSIFIED FLUOROSCOPIC X-RAY SYSTEM, MOBILE OXO MEDTRONIC NAVIGATION, INC. (LITTLETON) BI-700-00027-120

    Patients

    Seq Age Sex Outcome Treatment
    1