BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    O-ARM 1000 IMAGING SYSTEM

    MDR report key: 6129699 · Received November 28, 2016

    Report

    Report Number
    1723170-2016-03624
    Event Type
    Malfunction
    Date Received
    November 28, 2016
    Date of Event
    August 31, 2015
    Report Date
    November 28, 2016
    Manufacturer
    MEDTRONIC NAVIGATION, INC. (LITTLETON)
    Product Code
    OXO
    PMA / PMN Number
    K050996
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    NE, US
    Reporter Occupation
    HEALTH PROFESSIONAL

    Narratives

    Additional Manufacturer Narrative · 1

    PATIENT IDENTIFIER NOT AVAILABLE FROM THE SITE. PATIENT WEIGHT NOT AVAILABLE FROM THE SITE. A MEDTRONIC REPRESENTATIVE WENT TO THE SITE TO TEST THE EQUIPMENT ON (B)(4) 2015. TESTING FOUND THAT THE DOORS WOULD NOT OPEN UNTIL REPLACEMENT OF THE MOTION CONTROLLER. THE MOTION CONTROLLER WAS REPLACED, HOWEVER, THEM THE ROTOR WOULD ROCK. THE NEW MOTION CONTROLLER WAS DEEMED TO BE INOPERABLE DUE TO IT GENERATING ANOTHER ISSUE. A REPLACEMENT MOTION CONTROLLER WAS SHIPPED TO THE SITE AND THE REPLACEMENT WAS PERFORMED ON 2 SEPTEMBER 2015. THE IMAGING SYSTEM THEN PASSED THE SYSTEM CHECKOUT AND WAS FOUND TO BE FULLY FUNCTIONAL. THE MOTION CONTROLLER WAS RETURNED TO THE MANUFACTURER FOR ANALYSIS. THE GANTRY PORTION OF THE MOTION CONTROLLER WAS FOUND TO NOT BE ABLE TO REHOME AND WOULD NOT RECOGNIZE BOUNDARIES. THIS CONFIRMED AN ELECTRICAL FAILURE DUE TO THE GANTRY NOT BEING ABLE TO HOME. 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 SITE REPRESENTATIVE REPORTED THAT, WHILE IN A SPINAL FUSION, THE IMAGING SYSTEM WOULD NOT OPEN FROM AROUND THE PATIENT. THE SITE WAS ABLE TO MANUALLY OPEN THE IMAGING SYSTEM AND REMOVE IT TO CONTINUE WITH THE CASE. A CLICKING NOISE WAS OBSERVED WHEN ATTEMPTING TO OPEN IT AND THE OVERRIDE BUTTON ALSO GENERATED THE CLICKING NOISE. NO ADDITIONAL INFORMATION WAS PROVIDED. 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
    779117 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 67 YR