BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    O-ARM 1000 IMAGING SYSTEM 3RD EDITION

    MDR report key: 6106041 · Received November 16, 2016

    Report

    Report Number
    1723170-2016-05254
    Event Type
    Malfunction
    Date Received
    November 16, 2016
    Date of Event
    January 15, 2016
    Report Date
    November 16, 2016
    Manufacturer
    MEDTRONIC NAVIGATION, INC. (LITTLETON)
    Product Code
    OXO
    PMA / PMN Number
    K092564
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    MN, US
    Reporter Occupation
    HEALTH PROFESSIONAL

    Narratives

    Additional Manufacturer Narrative · 1

    NO PATIENT INFORMATION PROVIDED AS NO PATIENT WAS INVOLVED IN THIS CONCERN. A MEDTRONIC REPRESENTATIVE REPORTED THAT WHEN THE SITE WAS DRIVING THE IMAGING SYSTEM TO STORE IT, THE SYSTEM SHUT DOWN AND COULD NOT BE MOVED. THEY MANUALLY MOVED IT TO A STORAGE AREA. THEY NOTED THAT WHEN THE SYSTEM WAS PLUGGED IN THEY COULD NOT DRIVE IT. THEY UNPLUGGED THE UMBILICAL CABLE AND BOTH THE X-RAY AND MOTION BATTERIES WERE COMPLETELY DEPLETED. THE SITE NOTED THAT THEY NORMALLY STORED THE SYSTEM TURNED OFF AND PLUGGED IN. THIS WAS REPORTED OUTSIDE OF SURGERY. THERE WAS NO PATIENT PRESENT WHEN THIS ISSUE WAS IDENTIFIED. ONSITE INVESTIGATION WAS PERFORMED, AND THE FIELD ENGINEER DISCOVERED A LOOSE J13 CONNECTOR ON THE SYSTEM BOARD WHICH CAUSED THE REPORTED EVENT. RE-SEATING THE LOOSE CONNECTOR RESOLVED THE ISSUE. NO FURTHER ISSUES WERE REPORTED. 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 (B)(4) OFFICE ON (B)(6) 2016 VIA MEDTRONIC NAVIGATION, INC. RESPONSE TO (B)(6) 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 (B)(4) 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 (B)(6) 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 SITE WAS DRIVING THE IMAGING SYSTEM TO STORE IT, THE SYSTEM SHUT DOWN AND COULD NOT BE MOVED. THEY MANUALLY MOVED IT TO A STORAGE AREA. THEY NOTED THAT WHEN THE SYSTEM WAS PLUGGED IN THEY COULD NOT DRIVE IT. THEY UNPLUGGED THE UMBILICAL CABLE AND BOTH THE X-RAY AND MOTION BATTERIES WERE COMPLETELY DEPLETED. THE SITE NOTED THAT THEY NORMALLY STORED THE SYSTEM TURNED OFF AND PLUGGED IN. THIS WAS REPORTED OUTSIDE OF SURGERY. THERE WAS NO PATIENT PRESENT WHEN THIS ISSUE WAS IDENTIFIED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    757963 O-ARM 1000 IMAGING SYSTEM 3RD EDITION IMAGE-INTENSIFIED FLUOROSCOPIC X-RAY SYSTEM, MOBILE OXO MEDTRONIC NAVIGATION, INC. (LITTLETON) BI-700-00028-120

    Patients

    Seq Age Sex Outcome Treatment
    1