MAUDE Adverse Event Report: SIEMENS HEALTHCARE GMBH- AT ARTIS ZEEGO; INTERVENTIONAL FLUOROSCOPIC X-RAY SYSTEM

Model Number 10280959

Device Problem Mechanical Problem (1384)

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

Event Date 10/13/2021

Event Type  malfunction  

Manufacturer Narrative

Siemens is conducting a thorough investigation of the reported events.As this event is under investigation, a root cause has not yet been determined.A supplement report will be filed upon completion of the investigation.

Event Description

It was reported to siemens that a malfunction occurred while operating the artis zeego system.During an interventional procedure, the user reported that no movement was possible.The procedure was continued and completed on an alternate system.We are unaware of any impact to the state of health of the patient involved.Siemens has requested additional information in order to conduct an investigation of the reported event.

Manufacturer Narrative

Siemens has completed an investigation of the reported event.The root cause was determined to be an inaccurate parameter adjustment (geometry) on site.The investigation was performed considering complaint description, cs reports, system history, and system log files.In the robotic c-arm system, two room limitations are active for the range of motion, the first being the room limits set by the stand control units (scu).When these room limits are exceeded, the user is informed, but the robotic system is still moveable with the function override mode.This procedure is described in detail in the user manual and is also part of the training.The second set of limits are the robotic internally set limits (saferdw limits), which are slightly higher than the scu room limits.In normal operation, the user cannot drive into the saferdw limits.If the robot is exceeding those saferdw limits (e.G.Due to a system issue or an issue with the room limits) further movement is blocked for safety reasons (collision avoidance).Analysis of the log file showed that this override function was used but it was possible to drive the robot into the saferdw limits which inhibited further movements and which could only be resolved as part of service activity.The system behavior was caused by inaccurate parameter adjustment (geometry) on site.It is necessary to set such parameters on site, as the individual conditions at the customer sites are different.For example, the actual distances to the walls, floor and ceiling must be maintained.For this reason, the on-site service organization performed a full geometry adjustment again.After this, the issue could not be reproduced and the system is operating as specified.A possible general error that would require corrective measures of the installed base could not be determined by the investigation.After detailed investigation, the incident is not classified as a reportable event as neither serious injury, death nor an unexpected, prolonged hospitalization of the patient or any other person occurred or could be expected.

• Brand Name: ARTIS ZEEGO
• Type of Device: INTERVENTIONAL FLUOROSCOPIC X-RAY SYSTEM
• Manufacturer (Section D): SIEMENS HEALTHCARE GMBH- AT; siemensstrasse 1; forccheim, germany 91301 ; GM 91301
• Manufacturer (Section G): SIEMENS HEALTHCARE GMBH-AT; siemensstr. 1; forchheim, germany 91301 ; GM 91301
• Manufacturer Contact: meredith adams ; 40 liberty blvd.; malvern, PA 19355 ; 6104486461
• MDR Report Key: 12655374
• MDR Text Key: 277160027
• Report Number: 3004977335-2021-00849
• Device Sequence Number: 1
• Product Code: OWB
• UDI-Device Identifier: 04056869010083
• UDI-Public: 04056869010083
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K181407
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Company Representative
• Reporter Occupation: Other
• Remedial Action: Repair
• Type of Report: Initial,Followup
• Report Date: 10/19/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 10/19/2021
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: 10280959
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: No
• Date Manufacturer Received: 11/22/2021
• Was Device Evaluated by Manufacturer?: Yes
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1