MAUDE Adverse Event Report: AIZU OLYMPUS CO., LTD. EVIS EXERA III DUODENOVIDEOSCOPE

Model Number	TJF-Q190V
Medical Device Problem Code	Microbial Contamination of Device (2303)
Health Effect - Clinical Code	Unspecified Infection (1930)
Type of Reportable Event	Serious Injury
Event or Problem Description
The customer reported to olympus that during routine microbiological testing, the evis exera iii duodenovideoscope tested positive for an unexpected contamination.The testing was performed after a therapeutic endoscopic retrograde cholangiopancreatography procedure.The user did not report any contamination or any other serious deterioration in state of health of any person, to which the scope could have been a contributory cause.Additional information from the olympus employee reported that upon follow-up at the site and discussing the positive culture report with the customer, it was discovered the facility had two potential patients post procedure infections.Both instances the patient had an ercp- endoscopic retrograde cholangiopancreatography procedure before the infection and a culture positive scope was used in the procedure.The customer has not disclosed the date the scopes were cultured, and the type/growth of microbiological organism tested.The facility is reported to be inquiring further details from the infection prevention control.2 similar occurrrences have been reported by the customer for patients having post-procedure infections at their facility with the patient identifiers: 1) patient identifier # (b)(6) evis exera iii duodenovideoscope tjf-q190v, sn (b)(6) (this report).2) patient identifier # (b)(6) evis exera iii duodenovideoscope tjf-q190v sn -unk.

• Brand Name: EVIS EXERA III DUODENOVIDEOSCOPE
• Common Device Name: DUODENOVIDEOSCOPE
• Manufacturer (Section D): AIZU OLYMPUS CO., LTD.; 3-1-1 niiderakita; aizuwakamatsu-shi, fukushima 965-8 520; JA 965-8520
• MDR Report Key: 18489927
• Report Number: 2429304-2024-00017
• Device Sequence Number: 12958929
• Product Code: FDT
• UDI-Device Identifier: 04953170405563
• UDI-Public: 04953170405563
• Combination Product (Y/N): N
• Initial Reporter State: UT
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Importer
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 01/10/2024
• Report Date (Section F): 12/11/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Model Number: TJF-Q190V
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: Yes
• Distributor Facility Aware Date: 12/11/2023
• Device Age: 3 YR
• Event Location: Hospital
• Date Report to Manufacturer: 12/11/2023
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 01/10/2024
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other
• Patient Sex: Unknown