Block e1 (initial reporter facility name) (b)(6) hospital.Block h6 (impact codes): impact code f1001 is being used to capture the reportable event of aborted/cancelled procedure.The returned spyscope ds ii was analyzed, and a visual evaluation noted that there were no elevator marks on the shaft of the catheter.No damage was noted.Witness marks were observed on the contacts of the umbilicus connector, indicating it was connected to a controller.An image assessment for visualization was performed.The device was plugged into the controller.A live, clear image was displayed.No problems were observed with physical connectivity of the device.The umbilicus connector was visually inspected, and no damage or defects were noted.The device was fully articulated in all directions; no problems were identified with the image.X-ray imaging of the distal tip showed no problems with the redistribution layer (rdl) or thru-silicon vias (tsvs).X-ray imaging of the handle showed no problems with the printed circuit board assembly (pcba) or camera wires.The handle was opened and the components within were visually inspected.It was noted that there was procedural residue on the plastic optical fibers (pofs) and on the pcba board in the breakout region, indicated procedural fluids had flowed back up the optics lumen into the handle during use.The tip was blocked, and saline was flushed through the irrigation tubing to induce backflow of saline into the optics lumen.This caused loss of image.The saline was drained from the optics lumen and the image was restored.The reported complaint was confirmed.During product analysis, when saline was introduced in the optics lumen, image was lost.The image signal does not withstand the change in capacitance created by the introduction of saline into the optics lumen, and procedural factors can cause this fluid to enter the optics lumen during use.Based on all gathered information, the probable cause selected for the image failure due to fluid in the optics lumen is cause traced to device design, which indicates that the problems are traced to the design specifications.A labeling review was performed and, from the information available, this device was used per the instructions for use (ifu) / product label.
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