Model Number TJF-160VR |
Device Problem
Adverse Event Without Identified Device or Use Problem (2993)
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Patient Problem
Unspecified Infection (1930)
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Event Date 03/01/2019 |
Event Type
Injury
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Manufacturer Narrative
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Olympus reviewed the service history for the subject device.The olympus (b)(4) subsidiary had received the subject device for repair from the user facility in march 2019 before aware of the reported event.The evaluation results of the subject device by the olympus (b)(4) are as follows; there was an air leakage from the distal end.The instrument channel had wear and scratches.The adhesive of the rubber of the bending section had a wear and a tear.There were scratches on the distal end.There were scratches on the light guide lens.The subject device in this report has not been returned to olympus medical systems corp.(omsc) for evaluation.Omsc reviewed the manufacturing history (dhr) of the subject device and confirmed no irregularity.The exact cause of the reported event could not be conclusively determined at this time.If additional information becomes available, this report will be supplemented.
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Event Description
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Olympus medical systems corp.(omsc) was informed that the samples collected from five patients were tested positive for klebsiella spp, carbapenemase-producing enterobacteriaceae (cpe), new delhi metallo-beta-lactomase (ndm) or klebsiella pneumoniae after a procedure using an olympus duodenoscope (tjf-160vr) between (b)(6) 2019.First patient: the patient underwent a procedure for replacement of prosthesis after a migration using the subject device on (b)(6) 2019.It was reported that klebsiella spp, cpe and ndm were detected from the bile sample collected from the patient.Second patient: the patient underwent an endoscopic retrograde cholangiopancreatography (ercp) using the subject device on (b)(6) 2019.It was reported that cpe, ndm and klebsiella pneumoniae were detected from the bile and rectal samples collected from the patient.Third patient: the patient underwent a procedure for replacement of prosthesis using the subject device on (b)(6) 2019.It was reported that klebsiella pneumoniae, cpe and ndm were detected from the rectal sample collected from the patient.Fourth patient: the patient underwent an ercp using the subject device on (b)(6) 2019.It was reported that klebsiella pneumoniae, cpe and ndm were detected from the bile sample collected from the patient.Fifth patient: the patient underwent a procedure for replacement of biliary prosthesis using the subject device on (b)(6) 2019.It was reported that klebsiella pneumoniae, cpe and ndm were detected from the rectal sample collected from the patient.Five patients were colonized cpe.The device had been reprocessed with a non-olympus automated endoscope reprocessor, soluscope serie 3, using peracetic acid.Omsc is submitting five medical device reports according to the number of the patients.This is five of five reports.
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Manufacturer Narrative
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This supplemental report is being submitted to provide additional information.The initial mdr reported that five patient were infected with organisms.On june 27th, 2019, olympus medical systems corp.(omsc) was informed that the sample collected from another patient was tested positive for carbapenemase-producing enterobacteriaceae (cpe), new delhi metallo-beta-lactomase (ndm) or klebsiella pneumoniae after an endoscopic retrograde cholangiopancreatography using olympus duodenoscope (tjf-160vr) on (b)(6) 2019.The condition of the sixth patient involved in the event is currently unknown.The exact cause of the reported event could not be conclusively determined at this time.If additional information becomes available, this report will be supplemented.
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Manufacturer Narrative
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This supplemental report is being submitted to correct the ¿date of event¿.The exact cause of the reported event could not be conclusively determined.If additional information becomes available, this report will be supplemented.
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Manufacturer Narrative
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This supplemental report is being submitted to provide additional information.On may 28th, 2019, olympus followed up with the user facility and received additional information as follows; the endoscope unit of the user facility has permitted to use the subject device after the repair.There was no proof to show the association between infection and subject device.The user facility has not carried out antibiotic treatment for the patients.The exact cause of the reported event could not be conclusively determined at this time.If additional information becomes available, this report will be supplemented.
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Manufacturer Narrative
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This supplemental report is being submitted to provide additional information.On (b)(6), 2019, olympus medical systems corp.(omsc) was informed that as a result of the last microbiological testing by the user facility before the infection occurred, the subject device tested positive for unspecified microbes (2cfu/50ml).The exact cause of the reported event could not be conclusively determined.If additional information becomes available, this report will be supplemented.
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Search Alerts/Recalls
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