BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    O-ARM 1000 IMAGING SYSTEM

    MDR report key: 6131898 · Received November 29, 2016

    Report

    Report Number
    1723170-2016-03898
    Event Type
    Malfunction
    Date Received
    November 29, 2016
    Date of Event
    July 22, 2014
    Report Date
    November 29, 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
    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 REPORTED THAT DURING A DAILY QA CHECK THIS MORNING, THE IMAGING SYSTEM WAS NOT RESPONDING NORMALLY TO MOVEMENT COMMANDS. IN/OUT AND UP/DOWN WERE NORMAL, BUT OPEN/CLOSE WAS NOT RESULTING IN FULLY CLOSED DOOR. THE MEDTRONIC REPRESENTATIVE TRIED REOPENING AND RE-CLOSING MANY TIMES, EVENTUALLY THE REP WAS ABLE TO DO, SO SUCCESSFULLY, BUT AT THE START OF TEST THE DOOR WAS PHYSICALLY NOT CLOSING ALL THE WAY AND THEN NOT RESPONDING TO COMMAND TO OPEN. NO PATIENT WAS PRESENT DURING THE TIME OF THE REPORTED INCIDENT. AN ONSITE INSPECTION WAS SCHEDULED FOR A LATER DATE. DURING THE ONSITE INSPECTION, THE MEDTRONIC REPRESENTATIVE REPORTED THAT THE ISSUE COULD NOT BE REPLICATED. THE LOGS SHOWED AN ISSUE WITH THE MOTION CONTROLLER. THE MEDTRONIC REPRESENTATIVE REPLACED THE GANTRY MOTION CONTROLLER. THE REPLACED GANTRY MOTION CONTROLLER WAS SENT TO THE MANUFACTURER FOR PART ANALYSIS. A SUCCESSFUL SYSTEM CHECKOUT WAS PERFORMED WHICH VERIFIED THAT THE ISSUE HAD BEEN RESOLVED. THE PART ANALYSIS WAS UNABLE TO VERIFY THE REPORTED PART FAILURE. THIS EVENT WAS IDENTIFIED DURING A RETROSPECTIVE REVIEW AS DISCUSSED WITH THE FDA (B)(6) DISTRICT OFFICE ON APRIL 7, 2016 VIA MEDTRONIC NAVIGATION, INC. RESPONSE TO 3/17/2016 (B)(6). 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 DURING A DAILY QA CHECK THIS MORNING, THE IMAGING SYSTEM WAS NOT RESPONDING NORMALLY TO MOVEMENT COMMANDS. IN/OUT AND UP/DOWN WERE NORMAL, BUT OPEN/CLOSE WAS NOT RESULTING IN FULLY CLOSED DOOR. THE MEDTRONIC REPRESENTATIVE TRIED REOPENING AND RE-CLOSING MANY TIMES, EVENTUALLY THE REP WAS ABLE TO DO SO SUCCESSFULLY, BUT AT THE START OF TEST THE DOOR WAS PHYSICALLY NOT CLOSING ALL THE WAY AND THEN NOT RESPONDING TO COMMAND TO OPEN. NO PATIENT WAS PRESENT DURING THE TIME OF THE REPORTED INCIDENT. AN ONSITE INSPECTION WAS SCHEDULED FOR A LATER DATE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    783148 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