MAUDE Adverse Event Report: HOYA CORPORATION PENTAX TOKYO OFFICE PENTAX; SINGLE USE DISTAL END CAP WITH ELEVATOR

Model Number OE-A63

Device Problem Detachment of Device or Device Component (2907)

Patient Problem Laceration(s) of Esophagus (2398)

Event Date 08/17/2020

Event Type  Injury  

Manufacturer Narrative

(b)(4).

Event Description

Pentax medical was made aware of an event that occurred in the operating room during an endoscopic retrograde cholangiopancreatography(ercp) for tumor jaundice in the emea region.The user reported that a distal end cap(dec) was disconnected at the beginning of the examination in the stomach of the patient and was removed traumatically involving penax medical accessory model oe-a63, lot number 0011050(from (b)(6) report), used with a pentax medical video duodenoscope, model ed34-i10t2, serial number (b)(4).The dec was withdrawn with an extraction basket with esophagus wound and the examination was stopped.The user facility reported a complaint on 20-aug-2020 in regards to pentax medical video duodenoscope, model ed34-i10t2, serial number (b)(4) for bending rubber winding on the wrong position, insertion flexible tubing(ift) worn out.Investigation in-process.

Event Description

Per an email from pentax france on (b)(6) 2020, the user facility contacted pentax on (b)(6)2020, stating that the replacement duodenoscope i10t received as a replacement is not usable due to the presence of mist on the image in regards to pentax medical video duodenoscope, model ed34-i10t2, serial number (b)(6).Investigation in-process.

• Brand Name: PENTAX
• Type of Device: SINGLE USE DISTAL END CAP WITH ELEVATOR
• Manufacturer (Section D): HOYA CORPORATION PENTAX TOKYO OFFICE; tsutsujigaoka 1-1-110; akishima-shi, tokyo 196-0 012; JA 196-0012
• Manufacturer (Section G): HOYA CORPORATION PENTAX TOKYO OFFICE; tsutsujigaoka 1-1-110; akishima-shi, tokyo 196-0 012; JA 196-0012
• Manufacturer Contact: william (temporary) ; 3 paragon drive; montvale, NJ 07645 ; 8004315880
• MDR Report Key: 10577347
• MDR Text Key: 215928284
• Report Number: 9610877-2020-00159
• Device Sequence Number: 1
• Product Code: FDT
• Combination Product (y/n): N
• Reporter Country Code: FR
• PMA/PMN Number: K192245
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Foreign,Health Professional
• Reporter Occupation: Physician
• Type of Report: Initial,Followup,Followup
• Report Date: 06/15/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 09/23/2020
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: OE-A63
• Device Lot Number: 0011050
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Date Manufacturer Received: 08/24/2020
• Is the Device Single Use?: Yes
• Patient Sequence Number: 1
• Patient Outcome(s): Other