The customer reported to olympus the single use distal cover fell off from the evis exera iii duodenovideoscope during withdrawal of the scope at the end of an endoscopic retrograde cholangiopancreatography (ercp).The distal cover was not retrieved, and the patient was reportedly informed by the customer that the distal cover will pass.The ercp was technically difficult due to ampullary stenosis and haraldsson type 4 major papilla, but no maneuvers that could have been disrupting to the cap were done.The distal cap was also checked before use.There were no reports of patient harm.This event is reported under the following patient identifiers: (b)(6) - single use distal cover.(b)(6) - evis exera iii duodenovideoscope.
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This report is being supplemented to provide additional information based on the legal manufacturer's final investigation and fdt additionally, to provide information received through follow up from the customer and an correction to the initial (e1, e2, and e3).The customer confirmed no anti-fog agent was used on the scope lens and boson scientific endoglide water soluble lubrication was applied.After attaching the distal cover to the scope, the user did confirm that the cover was not damaged.The user did attach the distal cover to the scope and then pull or twist the cover to make sure it does not come off.The customer also believes the distal cover was pushed firmly until the hook shown in the attached image of the distal ring were fully visible within the distal cover opening.A review of the device history record found no deviations that could have caused or contributed to the reported issue.Based on the results of the investigation, it is possible that the distal cover did not completely go over hook at the distal end, which is insufficient attachment to the device.It made the cover easy to come off the device.However, the root cause of the phenomenon could not be specified.The event can be detected and prevented by following the instructions for use which state: "detection method is described in 4.1 of chapter 4 in operation manual.Preventive measure is described in 3.5 of chapter 3 in operation manual." olympus will continue to monitor field performance for this device.
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