BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    O-ARM 1000 IMAGING SYSTEM

    MDR report key: 6099724 · Received November 14, 2016

    Report

    Report Number
    1723170-2016-04024
    Event Type
    Malfunction
    Date Received
    November 14, 2016
    Date of Event
    May 22, 2015
    Report Date
    November 14, 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
    HEALTH PROFESSIONAL

    Narratives

    Additional Manufacturer Narrative · 1

    A MEDTRONIC REPRESENTATIVE REPORTED THAT WHILE IN A CERVICAL FUSION PROCEDURE, THE IMAGING SYSTEM DISPLAYED A CRITICAL BATTERY ERROR, AND THEN THE SYSTEM COULD NOT BE MOVED. AFTER RE-BOOTING TWICE THEY WERE ABLE TO GET THE SYSTEM TO TAKE A SUCCESSFUL SPIN AND CONTINUE WITH THE CASE. THEY NOTED THAT THE MOTION BATTERY LEVEL ONLY HAD TWO BARS, THE X-RAY BATTERY LEVEL APPEARED NORMAL. THERE WAS A REPORTED DELAY TO THE PROCEDURE OF LESS THAN 1 HOUR DUE TO THIS ISSUE. THERE WAS NO IMPACT ON PATIENT OUTCOME. ONSITE INVESTIGATION DISCOVERED THAT THE MOTION BATTERIES DID NOT HOLD SUFFICIENT CHARGE ALONG WITH INTERMITTENT SOFTWARE ISSUES. REPLACEMENT OF THE MOTION BATTERIES AND THE MOBILE VIEW STATION (MVS) COMPUTER RESOLVED THE ISSUE. NO FURTHER ISSUES WERE REPORTED. ANALYSIS OF THE RETURNED MOTION BATTERIES COULD NOT CONFIRM ANY FAILURE AS THEY HELD SUFFICIENT CHARGE DURING TESTING. ANALYSIS OF THE RETURNED MVS COMPUTER COULD NOT CONFIRM ANY FAILURE AS IT RAN DURING BENCH LEVEL TESTING WITHOUT PROBLEMS. A FULL IMAGING SYSTEM CHECK-OUT WAS COMPLETED 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 FDA NEW ENGLAND 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 MEDTRONIC REPRESENTATIVE REPORTED THAT WHILE IN A CERVICAL FUSION PROCEDURE, THE IMAGING SYSTEM DISPLAYED A CRITICAL BATTERY ERROR, AND THEN THE SYSTEM COULD NOT BE MOVED. AFTER RE-BOOTING TWICE THEY WERE ABLE TO GET THE SYSTEM TO TAKE A SUCCESSFUL SPIN AND CONTINUE WITH THE CASE. THEY NOTED THAT THE MOTION BATTERY LEVEL ONLY HAD TWO BARS, THE X-RAY BATTERY LEVEL APPEARED NORMAL. 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
    750899 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 53 YR