MAUDE Adverse Event Report: HOLOGIC, INC. FAXITRON CORE; CABINET, X-RAY SYSTEM

Model Number	COREVISION 5X10
Medical Device Problem Code	Use of Device Problem (1670)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	07/14/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
A device history record (dhr) review was conducted for the reported lot/serial number.The device was released meeting all qa specifications.We are currently unable to establish a relationship between the device and the issue reported.The device involved in this event was not returned for evaluation purposes therefore visual and functional analysis of the product could not be performed.The information obtained during complaint investigation will be included in our global complaint trending and product surveillance will continue to monitor complaints of this type for adverse trends.If the product is received or additional information is obtained, the investigation will be reopened accordingly per standard operating procedure.
Event or Problem Description
It was reported that on july 14th during an imaging procedure for a sample, the specimen fell off the drawer and into the machine.The staff weren´t able to retrieve the sample and the patient had to be rescheduled for a new tissue acquisitions procedure.No other information is available.
Additional Manufacturer Narrative
Please disregard this submission.Please refer to 1220984-2021-00001 which was submitted with the correct manufacturing number.
Additional Manufacturer Narrative
Please disregard initial submission.Please refer to 1220984-2021-00029 which was submitted with the correct manufacturing number.

• Brand Name: FAXITRON CORE
• Common Device Name: CABINET, X-RAY SYSTEM
• Manufacturer (Section D): HOLOGIC, INC.; 250 campus drive; marlborough, MA 01752
• MDR Report Key: 12256550
• Report Number: 1222780-2021-00217
• Device Sequence Number: 17454125
• Product Code: MWP
• UDI-Device Identifier: 00857069006005
• UDI-Public: (01)00857069006005(11)170201
• Combination Product (Y/N): N
• Initial Reporter Country: UK
• PMA/510(K) Number: K082432
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 08/19/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Health Professional
• Device Model Number: COREVISION 5X10
• Device Catalogue Number: COREVISION 5X10
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 07/14/2021
• Supplement Date Received by Manufacturer: 07/14/2021; 07/14/2021
• Initial Report FDA Received Date: 07/30/2021
• Supplement Report FDA Received Date: 08/19/2021; 08/19/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention