BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    O-ARM 1000 IMAGING SYSTEM 3RD EDITION

    MDR report key: 6129154 · Received November 28, 2016

    Report

    Report Number
    1723170-2016-05141
    Event Type
    Malfunction
    Date Received
    November 28, 2016
    Date of Event
    July 20, 2015
    Report Date
    November 28, 2016
    Manufacturer
    MEDTRONIC NAVIGATION, INC. (LITTLETON)
    Product Code
    OXO
    PMA / PMN Number
    K092564
    Product Problem
    Yes
    Report Source
    Manufacturer report
    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 WENT TO THE SITE TO TEST THE EQUIPMENT. THE REPRESENTATIVE REPORTED THAT THE ROTOR, GANTRY AND POSITIONER CONTROLLERS WERE REPLACED. THE IMAGING SYSTEM THEN PASSED THE SYSTEM CHECKOUT AND WAS FOUND TO BE FULLY FUNCTIONAL. THE SYSTEM CONTROL BOARD WAS RETURNED TO THE MANUFACTURER FOR ANALYSIS. TESTING FOUND THAT THE J3 CONNECTOR WITHIN THE SYSTEM WAS A MALE ENDING RATHER THAN FEMALE. THE POWER SWITCHING BOARD WAS RETURNED TO THE MANUFACTURER FOR ANALYSIS. TESTING FOUND THAT THE BOARD HAD A DAMAGED CAPACITOR ON THE SYSTEM. CONFIRMING AN ELECTRICAL FAILURE. THE MOTION CONTROL BOX WAS RETURNED TO THE MANUFACTURER FOR ANALYSIS. TESTING FOUND THAT EVEN THOUGH FIRMWARE ON THE POSITIONER PORTION LOADED, THAT MOTION WOULD NOT START. GANTRY MOTIONS WERE FOUND TO NOT ALLOW THE COMPLETION OF HOMING. THE ROTOR MOTION WAS CONFIRMED TO BE MALFUNCTIONING DUE TO A COLLIMATOR ERROR. THE MOTION CONTROL BOX OVERALL EXPERIENCED AN ELECTRICAL BASED FAILURE. 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 THE IMAGING SYSTEM WAS SPORADICALLY ENTERING STAND ALONE MODE AND THAT MOVEMENT WAS NOT POSSIBLE. THE IMAGING SYSTEM WOULD NOT START UP. NO ADDITIONAL INFORMATION WAS PROVIDED. THERE WAS NO PATIENT PRESENT WHEN THIS ISSUE WAS IDENTIFIED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    781353 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