MAUDE Adverse Event Report: AOMORI OLYMPUS CO., LTD. SINGLE USE INJECTOR; INJECTOR AND SHEATHSET

Model Number NM-401L-0425

Device Problem Obstruction of Flow (2423)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Date 12/27/2022

Event Type  malfunction  

Manufacturer Narrative

The subject device has been returned to olympus for evaluation.Visual inspection was performed on the device and found no abnormality on the tubing appearance.Observed no kinks inside the needle tube, and no crack around the injection port.The slider could extend or retract the needle smoothly.Further checking, when using a test syringe to inject water into the injection port, confirmed that fluid was able to expel out when the needle was in the sheath, but when the needle was out of the sheath, the fluid would not flow.No water leak was that from the tube sheath during water injection.The investigation is ongoing, and a definitive root cause of the reported event cannot be determined at this time.If additional information becomes available, this report will be supplemented accordingly.Product return receipt date is not available currently.

Event Description

The olympus territory manager reported (on behalf of the customer) that while using the single use injector, fluid was not dispensing through the syringe into the patient as intended.The surgeon had previously performed three other attempts with the same style of device during the procedure but was unable to get any fluid through the syringes with the three previous devices.The surgeon was successfully able to inject the solution using a fourth single-use injector device.The issue occurred during the therapeutic procedure, and the procedure was completed with a similar device.There was no procedural delay or additional devices associated with the event.There was no patient harm associated with the event.Related patient identifiers: (b)(6).(nm-401l-0425/single use injector/sn: 29v22) and (b)(6) (nm-401l-0425/single use injector/sn: 29v22).

Manufacturer Narrative

This report is being supplemented to provide additional information based on the legal manufacturer's final investigation.A review of the device history record found no deviations that could have caused or contributed to the reported issue.Based on the results of the investigation, the definitive root cause of the syringe issue could not be determined.The instruction manual identifies the following verbiage, which may have prevented the phenomenon: ¿straighten out the instrument before inspecting it.The instrument can be damaged if it is coiled while the handle is operated.Operate the slider slowly, otherwise the tube could buckle.¿ olympus will continue to monitor field performance for this device.

• Brand Name: SINGLE USE INJECTOR
• Type of Device: INJECTOR AND SHEATHSET
• Manufacturer (Section D): AOMORI OLYMPUS CO., LTD.; 2-248-1 okkonoki; kuroishi-shi, aomori 036-0 357; JA 036-0357
• Manufacturer (Section G): AOMORI OLYMPUS CO., LTD.; 2-248-1 okkonoki; kuroishi-shi, aomori
• Manufacturer Contact: todd brill ; 800 west park drive; westborough, MA 01581 ; 5082077661
• MDR Report Key: 16244201
• MDR Text Key: 308361472
• Report Number: 9614641-2023-00110
• Device Sequence Number: 1
• Product Code: FBK
• UDI-Device Identifier: 04953170382345
• UDI-Public: 04953170382345
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K902736
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: User Facility,Company Representative
• Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup
• Report Date: 03/01/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 01/25/2023
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: NM-401L-0425
• Device Lot Number: 29V22
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Was the Report Sent to FDA?: No
• Date Manufacturer Received: 02/09/2023
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 09/22/2022
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1