MAUDE Adverse Event Report: HOYA CORPORATION PENTAX TOKYO OFFICE PENTAX; SINGLE USE DISTAL END CAP WITH ELEVATOR

Model Number OE-A63

Device Problems Material Separation (1562); Material Twisted/Bent (2981); Naturally Worn (2988)

Patient Problem Insufficient Information (4580)

Event Date 08/17/2020

Event Type  Injury  

Event Description

Pentax medical was made aware of an event that occurred in the operating room during an endoscopic retrograde cholangiopancreatography(ercp) for tumor jaundice in the emea region.The user reported that a distal end cap(dec) was disconnected at the beginning of the examination in the stomach of the patient and was removed traumatically involving pentax medical accessory model oe-a63, lot number 0011050 (from ansm report), used with a pentax medical video duodenoscope, model ed34-i10t2, serial number (b)(4).The dec was withdrawn with an extraction basket with esophagus wound and the examination was stopped.The user facility reported a complaint on 20-aug-2020 in regards to pentax medical video duodenoscope, model ed34-i10t2, serial number (b)(4) for bending rubber winding on the wrong position, insertion flexible tubing(ift) worn out.Investigation in-process.

Event Description

Per an email from pentax france on 25-aug-2020, the user facility contacted pentax on 06-aug-2020, stating that the replacement duodenoscope i10t received as a replacement is not usable due to the presence of mist on the image in regards to pentax medical video duodenoscope, model ed34-i10t2, serial number (b)(6).Investigation in-process.

Manufacturer Narrative

Correction information: f7: follow up #01.F10 continued: international medical device regulators forum (imdrf) adverse event reporting.Health effect impact code: 4648 insufficient information.Component code: 424 cap.Summary: based on the investigation, the concluson was user mishandling and customer retraining was required.Pentax medical has not received any further information for this event and therefore, considers this medwatch report closed.

• Brand Name: PENTAX
• Type of Device: SINGLE USE DISTAL END CAP WITH ELEVATOR
• Manufacturer (Section D): HOYA CORPORATION PENTAX TOKYO OFFICE; tsutsujigaoka 1-1-110; akishima-shi, tokyo 196-0 012; JA 196-0012
• MDR Report Key: 10577326
• MDR Text Key: 208307513
• Report Number: 2518897-2020-00159
• Device Sequence Number: 1
• Product Code: FDT
• Combination Product (y/n): N
• Reporter Country Code: FR
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Distributor
• Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date: 06/15/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 09/23/2020
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: OE-A63
• Device Lot Number: 0011050
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: Yes
• Date Report Sent to FDA: 06/15/2023
• Distributor Facility Aware Date: 08/24/2020
• Event Location: Hospital
• Date Report to Manufacturer: 06/15/2023
• Patient Sequence Number: 1
• Patient Outcome(s): Other