This report is being supplemented to provide additional information based on the legal manufacturer's final investigation.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, the guidewire tip was torn, and the fracture shape suggests a brittle fracture.There were no marks on the guidewire tip where the guidewire was pressed against it.The root cause of the reported event is unable to be determined.However, the likely cause of the reported event is due to the following: 1) an attempt was made to insert the device into the endoscope while using the guide wire.2) when the angle between the distal end and the guide wire was large as shown in the following figure, the device was inserted into the endoscope.3) a force exceeding the resisting force was applied to the guide wire tip.This caused the guide wire tip to tear.The instruction manual contains a warning to the user regarding this event: - when using the guide wire, insert the instrument with its distal tip in parallel with the guide wire while holding the distal tip as shown in figure 4.20.Be careful not to forcibly insert the instrument with a sharp angle between the distal tip and the guide wire as shown in figure 4.21.This may damage the distal tip.- when using a guide wire, insert this product into the forceps plug of the endoscope while holding the tip and aligning the tip with the guide wire as shown in figure 4.20.Do not insert the tip and guide wire at a large angle as shown in figure 4.21.The guidewire tip may be damaged and may not be able to be inserted along the guidewire.Olympus will continue to monitor field performance for this device.
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