MAUDE Adverse Event Report: MAQUET SAS LUCEA 10 RAIL; DEVICE, MEDICAL EXAMINATION, AC POWERED

Model Number ARD568602993

Device Problems Crack (1135); Detachment of Device or Device Component (2907)

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

Event Date 10/04/2023

Event Type  malfunction  

Manufacturer Narrative

Additional information will be provided following the conclusion of the investigation.H3 other text : device not returned to manufacturer.

Event Description

On 4th october 2023 getinge became aware of an issue with one of our examination lights ¿ lucea 10 rail.Based on photographic evidence the headlight cover was broken with missing particles.It was stated by technician that it is a recurring fault for this client.The transparent cover had been thrown away, but the technician almost guarantee that particles were missing on the cover as on other occasions.There was no injury reported, however, we decided to report the issue in abundance of caution as any parts falling off during examination may lead to potential serious injury of the patient.

Event Description

On 4th october 2023 getinge became aware of an issue with one of our examination lights ¿ lucea 10 rail.Based on photographic evidence the headlight cover was broken with missing particles.The transparent cover had been thrown away, but the technician was of the opinion that particles were missing on the cover as on other occasions.There was no injury reported, however, we decided to report the issue in abundance of caution as any parts falling off during examination may lead to potential serious injury of the patient.

Manufacturer Narrative

Getinge became aware of an issue with one of our examination lights ¿ lucea 10 rail.Based on photographic evidence the headlight cover was broken with missing particles.The transparent cover had been thrown away, but technician was of the opinion that particles were missing on the cover as on other occasions.There was no injury reported, however, we decided to report the issue in abundance of caution as any parts falling off during examination may lead to potential serious injury of the patient.Defective parts transparent plastic cover - lucea 10 and l10-handle interface with flexible v2 were replaced and the device was returned to use.It was established that when the event occurred, the examination light did not meet its specification due to cracks and missing particles from cover, which contributed to the event the device was not being used for patient treatment upon the event occurrence.According to the information gathered, the issue was discovered during daily checking.Review of received customer product complaints related to investigated issue, revealed that there were no injuries to a user nor to a patient or operator when this particular malfunction occurred.We can assume that the failure ratio of cracks and missing particles on lucea 10/40 devices is moderate.A root cause analysis was performed by subject matter experts at manufacturing site.Based on some internal test done by maquet sas (ref: cre 12-085 for instance), only abnormal use (violent collisions, excessive pressure¿) or the use of incompatible cleaning products or protocol, can damage this device as reported in this complaint.Tests performed by getinge did not lead to cracks as reported in the complaint at hand.The cracks detected on the handle interface and transparent cover fixing points were probably caused by improper use, collisions, incompatible cleaning products or protocol.To prevent any incident the lucea10/40 instruction for use 01701 en12 mentions to check the integrity of the light heads during daily inspection and describes how to clean and disinfect the light head.This document includes some recommended products and some prohibited products.In order to avoid mechanical stresses applied on the transparent housing during use the lucea10/40 instruction for use 01701 en12 mentions to handle the light head by the handle.To prevent any incident the lucea10/40 instruction for use ifu 01701 en12 mentions to check the integrity of the light heads during daily inspection.(ifu_lucea_10_40_01701 en12, pages 22-25, 30).We believe the related devices are performing correctly in the market.We also believe that if the manufacturer recommendation had been followed the incident could have been avoided.Getinge shall continue to monitor for any further events of this nature and do not propose any further action at this time.The initial reporter was nursing assistant.The correction of b5 describe event or problem field deems required.This is based on the internal evaluation.Previous b5 describe event or problem: on 4th october 2023 getinge became aware of an issue with one of our examination lights ¿ lucea 10 rail.Based on photographic evidence the headlight cover was broken with missing particles.The transparent cover had been thrown away, but the technician was of the opinion that particles were missing on the cover as on other occasions.There was no injury reported, however, we decided to report the issue in abundance of caution as any parts falling off during examination may lead to potential serious injury of the patient.Corrected b5 describe event or problem: on 4th october 2023 getinge became aware of an issue with one of our examination lights ¿ lucea 10 rail.Based on photographic evidence the headlight cover was broken with missing particles.The transparent cover had been thrown away, but the technician was of the opinion that particles were missing on the cover as on other occasions.There was no injury reported, however, we decided to report the issue in abundance of caution as any parts falling off during examination may lead to potential serious injury of the patient.

• Brand Name: LUCEA 10 RAIL
• Type of Device: DEVICE, MEDICAL EXAMINATION, AC POWERED
• Manufacturer (Section D): MAQUET SAS; parc de limere; avenue de la pomme de pin; ardon
• Manufacturer (Section G): MAQUET SAS; parc de limere; avenue de la pomme de pin; ardon
• Manufacturer Contact: pascal jay ; parc de limere; avenue de la pomme de pin; ardon
• MDR Report Key: 17902546
• MDR Text Key: 325239391
• Report Number: 9710055-2023-00748
• Device Sequence Number: 1
• Product Code: KZF
• Combination Product (y/n): N
• Reporter Country Code: SP
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Foreign,User Facility,Company Representative
• Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date: 10/10/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 10/10/2023
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Model Number: ARD568602993
• Device Catalogue Number: ARD568602993
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: No
• Date Manufacturer Received: 01/22/2024
• Was Device Evaluated by Manufacturer?: No
• Date Device Manufactured: 12/16/2010
• Is the Device Single Use?: No
• Type of Device Usage: Reuse
• Patient Sequence Number: 1