BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    O-ARM 1000 IMAGING SYSTEM

    MDR report key: 6114147 · Received November 18, 2016

    Report

    Report Number
    1723170-2016-03690
    Event Type
    Malfunction
    Date Received
    November 18, 2016
    Date of Event
    March 25, 2016
    Report Date
    February 21, 2018
    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

    A MEDTRONIC REPRESENTATIVE REPORTED THAT THERE WAS A RING ARTIFACT IN THE 3D IMAGES TODAY. THE MEDTRONIC REPRESENTATIVE RAN THE RAD AND FLUORO GAIN CALIBRATIONS AND THE RING ARTIFACT WAS GONE IN THE NEXT 3D SPIN OF HIS MODEL. THE SYSTEM'S LOGS WERE SENT TO THE MANUFACTURER FOR ANALYSIS. THERE WAS NO PATIENT IMPACT REPORTED AND NO DELAY IN SURGERY. SURGERY PROCEEDED AS PLANNED. A SOFTWARE INVESTIGATION WAS CONDUCTED TO ANALYZE THE SYSTEM LOGS. THE INVESTIGATION CONCLUDED THIS WAS NOT A SOFTWARE RELATED ISSUE. 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.

    Additional Manufacturer Narrative · 1

    (B)(6).

    Description of Event or Problem · 1

    A MEDTRONIC REPRESENTATIVE REPORTED THAT THERE WAS A RING ARTIFACT IN THE 3D IMAGES TODAY. THE MEDTRONIC REPRESENTATIVE RAN THE RAD AND FLUORO GAIN CALIBRATIONS AND THE RING ARTIFACT WAS GONE IN THE NEXT 3D SPIN OF HIS MODEL. THE SYSTEM'S LOGS WERE SENT TO THE MANUFACTURER FOR ANALYSIS. THERE WAS NO PATIENT IMPACT REPORTED AND NO DELAY IN SURGERY. SURGERY PROCEEDED AS PLANNED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    763527 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 35 YR