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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: HOYA CORPORATION PENTAX TOKYO OFFICE PENTAX; IMAGINA PROCESSOR (INCLUDES I-SCAN)-INT
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HOYA CORPORATION PENTAX TOKYO OFFICE PENTAX; IMAGINA PROCESSOR (INCLUDES I-SCAN)-INT Back to Search Results
Model Number EPK-I5500C
Medical Device Problem Code Circuit Failure (1089)
Health Effect - Clinical Code No Clinical Signs, Symptoms or Conditions (4582)
Date of Event 03/17/2021
Type of Reportable Event Malfunction
Additional Manufacturer Narrative
Device manufacture date unknown.This device is classified as import for export, therefore 510k is not applicable.Model epk-i5500c-us is available in the usa with a 510k number k190805.Evaluation summary: it was caused due to the pcb failure.This report is being filed as part of the pentax backlog management plan.
 
Event or Problem Description
This event occurred at the time of before use.There was no report of patient harm.The led is on even though the button an the processor is off.
 
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Brand Name
PENTAX
Common Device Name
IMAGINA PROCESSOR (INCLUDES I-SCAN)-INT
Manufacturer (Section D)
HOYA CORPORATION PENTAX TOKYO OFFICE
tsutsujigaoka 1-1-110
akishima-shi, tokyo 196-0 012
JA  196-0012
MDR Report Key12250874
Report Number9610877-2021-10416
Device Sequence Number3635856
Product Code PEA
UDI-Device Identifier04961333232918
UDI-Public04961333232918
Combination Product (Y/N)N
Initial Reporter CountryGM
Number of Events Summarized1
Summary Report (Y/N)N
Serviced by Third Party (Y/N)Unknown
Reporter Type Manufacturer
Report Source foreign,health professional
Initial Reporter Occupation Physician
Type of Report Initial
Report Date (Section B) 07/30/2021
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
Operator of Device Health Professional
Device Model NumberEPK-I5500C
Was Device Available for Evaluation? Yes
Type of Report(Section G)Thirty-Day
Initial Date Received by Manufacturer 03/17/2021
Initial Report FDA Received Date07/30/2021
Is This a Single-Use Device that was
Reprocessed and Reused on a Patient? (Y/N)		 No
Patient Sequence Number1
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