Model Number M00545000 |
Device Problem
Mechanical Problem (1384)
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Patient Problem
No Clinical Signs, Symptoms or Conditions (4582)
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Event Date 12/20/2021 |
Event Type
malfunction
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Manufacturer Narrative
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(b)(4).The device has not been received for analysis.Upon receipt and completion of the failure analysis of the complaint device, if there is any further relevant information from that review, a supplemental medwatch will be filed.
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Event Description
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It was reported to boston scientific corporation that an rx cytology brush was prepared for use in the bile duct during an endoscopic retrograde cholangiopancreatography (ercp) endoscopic lithotripsy procedure performed on (b)(6) 2021.During preparation and outside the patient, the brush did not extend and it was reported that the patient was sedated when the event occurred.It was also reported that the patient could not accept the prolonged procedure which resulted in cancellation of the procedure.There were no patient complications reported as a result of this event.The patient's condition at the conclusion of the procedure was reported to be stable.
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Manufacturer Narrative
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Block h6: impact code f1001 is being used to capture the reportable issue of aborted/cancelled procedure.Block h10: investigation results one rx cytology brush was received for analysis.Visual analysis of the returned device revealed that the working length was kinked and the handle was kinked.Functional evaluation was performed and it was noted that there was resistance when the handle was actuated.The reported event was confirmed.It's most likely that user manipulation during the unpackaging of the device and/or some technique performed during the preparation of the device resulted in kinking the working length.Once the working length was kinked, the user may have experienced difficulties with extending the brush which may have led to them applying extra force kinking the handle.Based on the information available and the analysis performed, the most probable root cause for this problem is adverse event related to procedure.A review of the manufacturing documentation for this device revealed that no anomalies or deviations related to the event occurred during manufacturing.
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Event Description
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It was reported to boston scientific corporation that an rx cytology brush was prepared for use in the bile duct during an endoscopic retrograde cholangiopancreatography (ercp) endoscopic lithotripsy procedure performed on (b)(6) 2021.During preparation and outside the patient, the brush did not extend and it was reported that the patient was sedated when the event occurred.It was also reported that the patient could not accept the prolonged procedure which resulted in cancellation of the procedure.There were no patient complications reported as a result of this event.The patient's condition at the conclusion of the procedure was reported to be stable.
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Search Alerts/Recalls
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