MAUDE Adverse Event Report: MERGE HEALTHCARE MERGE CADSTREAM; IMAGING PROCESSING SYSTEM

Model Number 6.2.2.1184

Device Problem Improper or Incorrect Procedure or Method (2017)

Patient Problem No Known Impact Or Consequence To Patient (2692)

Event Date 01/22/2020

Event Type  malfunction  

Manufacturer Narrative

The issue, incorrect patient orientation on all study images, was caused by incorrect data entry at the mr scanner.This is not an issue or malfunction that was caused or contributed to by the merge cadstream medical device.Cause due to an error by a technician at the scanner.No known impact to patient.No further actions are anticipated at this time.

Event Description

Cadstream is intended to be used in the visualization, analysis, and reporting of magnetic resonance imaging (mri) studies.Cadstream supports evaluation of dynamic mr data acquired during contrast administration.Cadstream performs other user selected processing functions (such as image registration, subtractions, measurements, 3d renderings, and reformats).On (b)(6) 2020, merge technical support was contacted by a user at a facility for assistance with correcting a study with incorrect patient orientation.The patient's orientation was entered at the scanner incorrectly.Cadstream is prohibited from editing or modifying image dicom data, including patient orientation and laterality, received from other application entities.Study results have the potential to become part of the patient's permanent record and records have the potential to impact a patient's treatment, therefore there is a possibility for a misdiagnosis or mistreatment that could lead to harm.There is no indication that this issue as reported by the customer has resulted in any harm to a patient.(b)(4).

• Brand Name: MERGE CADSTREAM
• Type of Device: IMAGING PROCESSING SYSTEM
• Manufacturer (Section D): MERGE HEALTHCARE; 75 binney st; cambridge, ma
• Manufacturer (Section G): MERGE HEALTHCARE; 75 binney st; cambridge, ma
• Manufacturer Contact: brian bell ; 75 binney st; cambridge, ma ; 3540189
• MDR Report Key: 9729522
• MDR Text Key: 190811555
• Report Number: 2183926-2020-00004
• Device Sequence Number: 1
• Product Code: LLZ
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K092954
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: user facility
• Reporter Occupation: Administrator/Supervisor
• Type of Report: Initial
• Report Date: 01/22/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 02/19/2020
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: 6.2.2.1184
• Was Device Available for Evaluation?: Yes
• Date Manufacturer Received: 01/22/2020
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 07/17/2018
• 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