This supplemental report is being submitted to provide the results of the legal manufacturer's final investigation. new information added on fields: d9, e2, e3, h3, h4 and h6.A review of the device history record found no deviations that could have caused or contributed to the reported issue.It has been over 12 years since the subject device was manufactured. no device was returned to olympus for evaluation.However, as part of the investigation into this report, an olympus endoscopy support specialist (ess) had been dispatched on-site to assess the reprocessing practices at the user facility.Based on the observation summary report, there were some reprocessing deviations observed during the visit, and they are as follows: the leakage test was improperly conducted.The endoscope was not depressurized at all during the leakage test process.During manual cleaning, the process of suction cleaning steps was not being completed.Ess noted that the leak testing error was believed to be a one-time situation, as this is not something that has been observed in the past.The leak testing error was also corrected while on-site, and proper training was provided on leak testing.Ess completed the repair reduction observation during leak testing, manual cleaning, transportation, and storage.Ess also performed a review of the correct leak testing process with the user facility staff, along with the training materials for their reference.Based on the results of the investigation, there was a difference in recognition on device handling or reprocessing steps between olympus recommendation and the user facility.The event can be prevented by following the instructions for use which state: evis exera ii gif/cf/pcf type 180 series reprocessing manual chapter 5 reprocessing the endoscope (and related reprocessing accessories).Olympus will continue to monitor field performance for this device. .
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