BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    O-ARM 1000 IMAGING SYSTEM

    MDR report key: 6086132 · Received November 8, 2016

    Report

    Report Number
    1723170-2016-04143
    Event Type
    Malfunction
    Date Received
    November 8, 2016
    Date of Event
    August 18, 2015
    Report Date
    November 8, 2016
    Manufacturer
    MEDTRONIC NAVIGATION, INC. (LITTLETON)
    Product Code
    OXO
    PMA / PMN Number
    K050996
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CO, US
    Reporter Occupation
    MEDICAL EQUIPMENT COMPANY TECHNICIAN/REPRESENTATIVE

    Narratives

    Additional Manufacturer Narrative · 1

    NO PATIENT INFORMATION PROVIDED AS NO PATIENT WAS INVOLVED IN THIS CONCERN. A MEDTRONIC REPRESENTATIVE REPORTED THAT WHEN THE IMAGING SYSTEM WAS BOOTED WITH THE DOOR OPENED, OR DOCKED, THE MOBILE VIEW STATION (MVS) SCREEN WOULD TURN COMPLETELY BLACK. THE WORK-AROUND WAS TO HIT THE ESC BUTTON ON THE KEYBOARD AND THE MVS WOULD GO BACK TO NORMAL. THE MEDTRONIC REPRESENTATIVE TRIED TO BOOT THE MVS WITH THE DOOR IN VARIOUS POSITIONS WHICH DID NOT RESOLVE THE ISSUE. THE MEDTRONIC REPRESENTATIVE SENT THE SYSTEM LOGS TO THE MANUFACTURER FOR ANALYSIS. NO PATIENT WAS PRESENT DURING THE TIME OF THE REPORTED INCIDENT. AN ON SITE INSPECTION WAS SCHEDULED FOR A LATER DATE. DURING THE ON SITE INSPECTION, THE MEDTRONIC REPRESENTATIVE FOUND THAT WHEN TRYING TO ADJUST THE NVIDEA SETTINGS ONLY A SINGLE OUTPUT WAS AVAILABLE FOR SELECTION. WHEN TROUBLESHOOTING THIS FURTHER IT WAS FOUND THE SYSTEM'S VIDEO SPLITTER HAD NO LIGHTS OR LEDS SHOWING. THE VIDEO SPLITTER WAS REPLACED. A SUCCESSFUL SYSTEM CHECKOUT WAS PERFORMED WHICH VERIFIED THAT THE ISSUE HAD BEEN RESOLVED. THE REPLACED VIDEO SPLITTER WAS SENT TO THE MANUFACTURER FOR PART ANALYSIS. DURING PART ANALYSIS, THERE WAS A CONFIRMED ELECTRICAL FAILURE FOR THE PART. A SOFTWARE INVESTIGATION WAS CONDUCTED TO ANALYZE THE SYSTEM LOGS WHERE IT WAS DETERMINED THAT THE REPORTED EVENT WAS RELATED TO A SOFTWARE ISSUE. THIS ISSUE WAS DOCUMENTED IN A MEDTRONIC NAVIGATION SOFTWARE ANOMALY TRACKING DATABASE. THIS EVENT WAS IDENTIFIED DURING A RETROSPECTIVE REVIEW AS DISCUSSED WITH THE FDA (B)(6) 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 MEDTRONIC REPRESENTATIVE REPORTED THAT WHEN THE IMAGING SYSTEM WAS BOOTED WITH THE DOOR OPENED, OR DOCKED, THE MOBILE VIEW STATION (MVS) SCREEN WOULD TURN COMPLETELY BLACK. THE WORK-AROUND WAS TO HIT THE ESC BUTTON ON THE KEYBOARD AND THE MVS WOULD GO BACK TO NORMAL. THE MEDTRONIC REPRESENTATIVE TRIED TO BOOT THE MVS WITH THE DOOR IN VARIOUS POSITIONS WHICH DID NOT RESOLVE THE ISSUE. THE MEDTRONIC REPRESENTATIVE SENT THE SYSTEM LOGS TO THE MANUFACTURER FOR ANALYSIS. NO PATIENT WAS PRESENT DURING THE TIME OF THE REPORTED INCIDENT. AN ON SITE INSPECTION WAS SCHEDULED FOR A LATER DATE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    737344 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