BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    O-ARM 1000 IMAGING SYSTEM

    MDR report key: 6082896 · Received November 7, 2016

    Report

    Report Number
    1723170-2016-03310
    Event Type
    Malfunction
    Date Received
    November 7, 2016
    Date of Event
    November 16, 2015
    Report Date
    November 7, 2016
    Manufacturer
    MEDTRONIC NAVIGATION, INC. (LITTLETON)
    Product Code
    OXO
    PMA / PMN Number
    K050996
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    FL, US
    Reporter Occupation
    HEALTH PROFESSIONAL

    Narratives

    Additional Manufacturer Narrative · 1

    PATIENT WEIGHT NOT AVAILABLE FROM THE SITE. A MEDTRONIC REPRESENTATIVE WENT TO THE SITE TO TEST THE EQUIPMENT. A REPLACEMENT BATTERY CHARGER AND 9AMPH 12V BATTERIES WERE SHIPPED TO THE SITE. AFTER REPLACING THE BATTERY CHARGER AND 9AMPH 12V BATTERIES, THE MEDTRONIC REPRESENTATIVE PERFORMED AN IMAGING SYSTEM CHECK-OUT, ALL AREAS PASSED. SYSTEM PERFORMED AS INTENDED. INVESTIGATION OF THE RETURNED SUSPECT BATTERY CHARGER FOUND THAT THE BATTERY INDICATOR LEDS DID NOT LIGHT ON RESTART. THE BATTERY CHARGER FAILED THE BENCH TEST. THE CHARGER CIRCUIT D READ 0 VOLTS ON ALL ITS OUTPUTS. THE 8-PACK BATTERY KIT WAS DISCARDED BY THE SITE AND WILL NOT BE RETURNED TO MANUFACTURER FOR ANALYSIS. (B)(4). 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 WHILE IN A PROCEDURE, HE WAS ABLE TO TAKE A 2D IMAGE ON THE SECOND PASS, BUT WHEN HE WENT INTO 3D MODE, HE WAS UNABLE TO TAKE A 3D IMAGE. THE SITE REPRESENTATIVE HEARD A BEEPING ALARM COMING FROM THE IMAGE ACQUISITION SYSTEM (IAS) AND RESTARTED THE IAS AND MOBILE VIEW STATION (MVS). THE X-RAY BATTERY INDICATOR WAS SHOWING NO BARS. THE MOTION CONTROL BATTERIES WERE ONLY MISSING TWO BARS. THE SURGEON COMPLETED THE PROCEDURE WITH THE USE OF THE NAVIGATION SYSTEM. THE SURGEON COMPLETED THE PROCEDURE WITH THE USE OF THE IMAGING SYSTEM. THERE WAS A REPORTED DELAY TO THE PROCEDURE OF LESS THAN 1 HOUR DUE TO THIS ISSUE. THERE WAS NO IMPACT ON PATIENT OUTCOME.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    732622 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 14 YR