O-ARM 1000 IMAGING SYSTEM
Report
- Report Number
- 1723170-2016-04806
- Event Type
- Malfunction
- Date Received
- November 7, 2016
- Date of Event
- November 26, 2014
- 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
- UT, US
- Reporter Occupation
- HEALTH PROFESSIONAL
Narratives
NO PATIENT INFORMATION PROVIDED AS NO PATIENT WAS INVOLVED IN THIS CONCERN. A SITE REPRESENTATIVE REPORTED THAT THE IMAGING SYSTEM WAS NOT CHARGING. THEY TRIED SEVERAL OUTLETS WITH NO IMPROVEMENT. THE GREEN LINE POWER LIGHT ON THE MOBILE VIEW STATION (MVS) WAS NOT LIT. ALSO, THE X AND M BATTERY INDICATORS WERE NOT SCROLLING. THE SITE IS PART OF A SHARED BIO MED AGREEMENT. THERE WAS NO PATIENT PRESENT WHEN THIS ISSUE WAS IDENTIFIED. ONSITE INVESTIGATION WAS NOT POSSIBLE AS THE SITE WAS A PART OF THE SHARED BIOMED PROGRAM. THE SITE'S BIOMEDICAL ENGINEER WAS WALKED THROUGH REPLACING THE DISCOVERED BLOWN FUSES ON THE MVS BOARD (F11 AND F12). REPLACEMENT OF THE FUSES RESOLVED THE ISSUE. NO FURTHER ISSUES WERE REPORTED. NO ANALYSIS OF THE BLOWN FUSES IS POSSIBLE AS THEY WERE NOT RETURNED TO MANUFACTURER. A SUBSEQUENT FULL IMAGING SYSTEM CHECK-OUT WAS COMPLETED (NOT SPECIFIC TO THIS CASE) AND ALL TESTS PASSED. FULL SYSTEM FUNCTIONALITY WAS CONFIRMED AND THE SYSTEM WAS RETURNED TO SERVICE. THIS EVENT WAS IDENTIFIED DURING A RETROSPECTIVE REVIEW AS DISCUSSED WITH THE (B)(6) DISTRICT OFFICE ON (B)(6) 2016 VIA MEDTRONIC NAVIGATION, INC. RESPONSE TO 3/17/2016 (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.
A SITE REPRESENTATIVE REPORTED THAT THE IMAGING SYSTEM WAS NOT CHARGING. THEY TRIED SEVERAL OUTLETS WITH NO IMPROVEMENT. THE GREEN LINE POWER LIGHT ON THE MOBILE VIEW STATION (MVS) WAS NOT LIT. ALSO, THE X AND M BATTERY INDICATORS WERE NOT SCROLLING. THE SITE IS PART OF A SHARED BIO MED AGREEMENT. THERE WAS NO PATIENT PRESENT WHEN THIS ISSUE WAS IDENTIFIED.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 734070 | 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 |