Brand Name | EVIS EXERA III XENON LIGHT SOURCE |
Type of Device | XENON LIGHT SOURCE |
Manufacturer (Section D) |
SHIRAKAWA OLYMPUS CO., LTD. |
3-1 okamiyama |
odakura, nishigo-mura, |
nishishirakawa-gun, fukushima 961-8 061 |
JA 961-8061 |
|
Manufacturer (Section G) |
SHIRAKAWA OLYMPUS CO., LTD. |
3-1 okamiyama |
odakura, nishigo-mura, |
nishishirakawa-gun, fukushima |
|
Manufacturer Contact |
todd
brill
|
800 west park drive |
westborough, MA 01581
|
5082077661
|
|
MDR Report Key | 18871771 |
MDR Text Key | 337757530 |
Report Number | 3002808148-2024-02241 |
Device Sequence Number | 1 |
Product Code |
NWB
|
UDI-Device Identifier | 04953170298868 |
UDI-Public | 04953170298868 |
Combination Product (y/n) | N |
Reporter Country Code | US |
PMA/PMN Number | K131780 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
Health Professional,User Facility |
Reporter Occupation |
Nurse
|
Type of Report
| Initial,Followup |
Report Date |
04/16/2024 |
1 Device was Involved in the Event |
|
1 Patient was Involved in the Event |
|
Is this an Adverse Event Report? |
No
|
Is this a Product Problem Report? |
Yes
|
Device Operator |
Health Professional
|
Device Model Number | CLV-190 |
Was Device Available for Evaluation? |
Device Returned to Manufacturer
|
Date Returned to Manufacturer | 03/01/2024 |
Is the Reporter a Health Professional? |
Yes
|
Was the Report Sent to FDA? |
No
|
Initial Date Manufacturer Received |
02/26/2024 |
Initial Date FDA Received | 03/08/2024 |
Supplement Dates Manufacturer Received | 04/09/2024
|
Supplement Dates FDA Received | 04/16/2024
|
Was Device Evaluated by Manufacturer? |
Yes
|
Date Device Manufactured | 04/15/2019 |
Is the Device Single Use? |
No
|
Is This a Reprocessed and Reused Single-Use Device? |
No
|
Type of Device Usage |
Reuse
|
Patient Sequence Number | 1 |
|
|