BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    PENTAX

    MDR report key: 8949125 · Received August 30, 2019

    Report

    Report Number
    9610877-2019-00024
    Event Type
    Malfunction
    Date Received
    August 30, 2019
    Report Date
    January 5, 2018
    Manufacturer
    HOYA CORPORATION PENTAX TOKYO OFFICE
    Product Code
    FDT
    PMA / PMN Number
    K092710
    Removal / Correction Number
    NOT ISSUED YET
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    TX, US
    Reporter Occupation
    003

    Narratives

    Additional Manufacturer Narrative · 1

    HOYA CORPORATION PENTAX (B)(4) OFFICE, SPECIFICATION DEVELOPER, REGISTRATION NO. (B)(4). PENTAX OF AMERICA, INC., IMPORTER, REGISTRATION NO. (B)(4). PENTAX OF AMERICA, INC. (IMPORTER) IS SUBMITTING THE REPORT ON BEHALF OF HOYA CORPORATION PENTAX (B)(4) OFFICE (EXEMPTION NUMBER E2015036). BASED ON DISCUSSION WITH FDA ON MAY 8, 2017, ALL INSPECTIONAL FAILURES ARE BEING REPORTED AS MDRS NOTWITHSTANDING THE FACT THAT THE PRESENCE OF DISCONTINUITIES, GAPS OR BUBBLES DOES NOT NECESSARILY HAVE EITHER TECHNICAL OR CLINICAL SIGNIFICANCE. (B)(4). NOTES: INITIAL MDR ORIGINALLY SUBMITTED TO THE FDA ON 11JAN2019, BUT THERE WAS AN ERROR IN FDA ACKNOWLEDGEMENT. RESUBMITTING ON AS PART OF A DELIVERY MESSAGE REVIEW.

    Description of Event or Problem · 1

    PENTAX OF AMERICA INITIATED FIELD CORRECTION 2017-001-C WHICH INCLUDED INSPECTION OF THE SEAL AROUND THE DISTAL BODY AND DISTAL CAP OF THE ED-3490TK DUODENOSCOPE PURSUANT TO PREDEFINED INSPECTION CRITERIA ((B)(4)). THE OBJECTIVE OF THE INSPECTION WAS TO VERIFY THERE WERE NO DEFECTS/DISCONTINUITIES IN THE SEAL BETWEEN THE DISTAL BODY AND DISTAL CAP. THE INSPECTIONAL CRITERIA WAS DEFINED AS, "ALL SEAL SURFACES OBSERVED SHALL BE CONTINUOUS AND SMOOTH WITH NO OUTWARD SIGNS OF DISCONTINUITY, GAPS OR BUBBLES." A DEVICE WAS CONSIDERED TO FAIL THE INSPECTION IF ANY ELEMENT OF THE CRITERIA WAS NOT MET. A LOANER DEVICE WAS PREVIOUSLY RETURNED TO PENTAX MEDICAL FROM A CUSTOMER ON 29/DEC/2017 AND INSPECTION OF THE UNIT WAS PERFORMED ON 05/JAN/2018 WHERE THE QUALITY CONTROL INSPECTOR FOUND THE FOLLOWING: SHADOW AT CORNER OF IMAGE, FLUID INVASION IN CONTROL BODY, AIR/ WATER SOCKET CYLINDER O-RING CHIPPED, PRISM SCRATCHED, DISTAL CAP - FIXED TYPE FAILED SEAL INTEGRITY INSPECTION, FAILED DRY LEAK TEST, ENDOSCOPE FAILED ELECTRICAL SAFETY TEST - HI-POT, ENDOSCOPE FAILED ELECTRICAL SAFETY TEST - PLCT, FAILED WET LEAK TEST, LEAK AT SIDE BODY COVER, FLUID INVASION NOT OBSERVED IN PVE CONNECTOR, SIDE BODY COVER O-RING STICKING OUT, HOLE IN # 2 REMOTE CONTROL BUTTON COVER, OPERATION CHANNEL TWISTED IN BENDING SECTION, CUSTOMER COMPLAINT CONFIRMED, CONTROL BODY MILD CORROSION INSIDE. INSPECTION OF THE SEAL BETWEEN THE DISTAL BODY AND DISTAL CAP WAS PERFORMED AND THE DEVICE FAILED THE INSPECTION CRITERIA. THE SCOPE'S REPAIRS INCLUDE THE DISTAL CASE/CAP, WHICH WAS REPLACED AND/OR RESEALED PURSUANT TO THE FIELD CORRECTION, ALONG WITH MISCELLANEOUS PARTS, AND RETURNED TO INVENTORY. (DUPLICATE OF (B)(4)). PARTS REPLACED: AIR/WATER TUBE, DEFLECTOR OPERATING WIRE, OBJECTIVE PRISM ASSY, OPERATION CHANNEL, ADJUSTING COLLAR, BENDING RUBBER, SEGMENT ATTACHING SCREW, DISTAL CASE/CAP, INSERTION FLEXIBLE TUBE, ROOT BRACE RUBBER, SEGMENT ASSY ATTACHING SCREW, STAYCOIL COLLAR, SEGMENT STAYCOIL ASSY IMP-C/PB-FREE, BODY COVER GRIP, FWD BODY TRIM COLLAR, RUBBER TRIM COLLAR, RL LOCK KNOB RETAINING NUT COVER, RL PULLEY ASSY, UD PULLEY ASSY, CONNECTING RECEPTACLE(2), CONNECTING RECEPTACLE (3), BUTTON CASE LID, REMOTE CONTROL BUTTON(1), AIR/WATER SUPPLY TUBE LG, ROOT BRACE RUBBER LG BODY, SIDE BODY COVER, SUCTION CHANNEL LG, ROOT BRACE RUBBER LG CONNECTOR, LIGHT GUIDE CABLE, LG CABLE CONNECTOR HOUSING PB-FREE, RL LOCK ROTATING DISK, RL LOCK BASE UNIT, DEFLECTOR LEVER ATTACHING NUT, MFR LABEL E-HOYA NON-CE (S).

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    744424 PENTAX VIDEO DUODENOSCOPE FDT HOYA CORPORATION PENTAX TOKYO OFFICE ED-3490TK

    Patients

    Seq Age Sex Outcome Treatment
    1