MAUDE Adverse Event Report: PHILIPS HEALTHCARE (SUZHOU) CO., LTD. INGENUITY CT; SYSTEM, X-RAY, TOMOGRAPHY, COMPUTED

Model Number INGENUITY CT

Device Problem Unintended System Motion (1430)

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

Event Date 04/17/2023

Event Type  malfunction  

Manufacturer Narrative

Note: we have not completed our investigation of this event.We will file a follow-up emdr at the completion of the investigation.Internal cross reference: complaint pr# (b)(4).

Event Description

This complaint has been evaluated based on the information provided.The customer reported that while raising the couch with patient on table, the couch suddenly dropped to the floor.Philips field service engineer(fse) inspected system and identified that couch ball screw was broken.Fse replaced both ball bearing and ball screw, system was returned to the customer for clinical use after parts replacement.There was no report of harm.We are considering this event reportable out of abundance of caution.Philips has started an investigation of this complaint.

Manufacturer Narrative

The customer reported that while raising the couch with patient on table, the couch suddenly dropped to the floor.Philips field service engineer (fse) inspected system and identified that couch ball screw was broken.Fse replaced both ball bearing and ball screw, system was returned to the customer for clinical use after parts replacement.There was no report of harm.Inspection of the failed parts was performed by the sz research and development (r&d), and it was confirmed that the vertical ball screw had fractured.The failed vertical ball screw was further analyzed by the 3rd party laboratory suzhou metal services co, ltd whom confirmed that the ball screw fractured was due to fatigue failure.The ball screw inventory was also checked, all the parts meet the drawing spec, therefore, material and supplier quality issue was excluded from failure root cause.Couch manufacturing process for ball screw alignment and installation were checked through tolerance stack up and production couch alignment accuracy measurement.The calculation shows the production alignment can meet the spec.Sampling checked the production couch measurement accuracy were all within spec.Couch manufacturing can be excluded for failure root cause.According to the design analysis, ball screw excessive misalignment was determined to be the root cause of the fatigue.During the site inspection, the upgrade kit was not installed on couch in previous ball screw replacement.Fse was not familiar with alignment solution (alignment procedure, upgrade kit).According to the service data analysis for the similar complaints, the alignment tool and upgrade kit were missing in service record.Corrections: released vertical drive replacement tool kit (alignment tool) in spare parts system (sps) to make it available for fse to ensure they can use it during vertical parts replacement process.Updated ingenuity series patient support repair and replacement manual to define using vertical drive replacement tool kit (alignment tool) in section ¿vertical motor and vertical drive extended support bearing retainer alignment procedure and vertical motor and vertical drive standard¿ and section ¿bariatric support bearing retainer alignment procedure¿ to ensure fses use the tool during vertical parts replacement process.Updated trouble shooting manuals and troubleshooting guide to add ball screw inspection details in section mechanically related couch problem.Internal cross reference: complaint (b)(4).

Event Description

This complaint has been evaluated based on the information provided.The customer reported that while raising the couch with patient on table, the couch suddenly dropped to the floor.Philips field service engineer(fse) inspected system and identified that couch ball screw was broken.Fse replaced both ball bearing and ball screw, system was returned to the customer for clinical use after parts replacement.There was no report of harm.We considered this event reportable out of abundance of caution.Philips has now completed the investigation of this complaint.

• Brand Name: INGENUITY CT
• Type of Device: SYSTEM, X-RAY, TOMOGRAPHY, COMPUTED
• Manufacturer (Section D): PHILIPS HEALTHCARE (SUZHOU) CO., LTD.; no. 258, zhongyaun road; suzhou industrial park; suzhou jiangsu 21502 4; CH 215024
• Manufacturer (Section G): PHILIPS HEALTHCARE (SUZHOU) CO., LTD.; no. 258, zhongyaun road; suzhou industrial park; suzhou jiangsu 21502 4; CH 215024
• Manufacturer Contact: estelle hilas ; 100 park avenue, suite 300; orange village, OH 44122
• MDR Report Key: 17033634
• MDR Text Key: 316253075
• Report Number: 3009529630-2023-00005
• Device Sequence Number: 1
• Product Code: JAK
• UDI-Device Identifier: 00884838059511
• UDI-Public: 00884838059511
• Combination Product (y/n): N
• Reporter Country Code: KS
• PMA/PMN Number: K160743
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Foreign,Health Professional,User Facility
• Reporter Occupation: Other Health Care Professional
• Remedial Action: Replace
• Type of Report: Initial,Followup

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 05/31/2023
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: INGENUITY CT
• Device Catalogue Number: 728326
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 04/17/2023
• Was Device Evaluated by Manufacturer?: Yes
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Reuse
• Patient Sequence Number: 1