MAUDE Adverse Event Report: STRYKER ENDOSCOPY-SAN JOSE L9000 LIGHTSOURCE INTERNATIONAL KIT; LIGHT SOURCE, FIBEROPTIC, ROUTINE

Model Number	0220210000
Medical Device Problem Codes	No Device Output (1435); Output Problem (3005)
Health Effect - Clinical Codes	Insufficient Information (4580); No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	07/13/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Additional information will be provided once the investigation has been completed.The device manufacturer date is not known at this time.However, should it become available it will be provided in future reports.
Event or Problem Description
It was reported that there was loss of light.
Additional Manufacturer Narrative
This complaint investigation was closed based on the device not received, therefore the reported failure mode was not confirmed.In the event that the device is received, the complaint will be reopened and the investigation will be updated with new results.The reported failure mode will be monitored for future reoccurrence.Alleged failure: image loss probable root cause: light cable, optics, leds, main board, jaw assembly, bent esst contact, inconsistent esst contact, cable pull out, camera head, firewire cable, software, front board, power supply, thermal switch, ac inlet board, ac inlet filter, touch screen, workmanship, inadequate air flow, inadequate calibration, excessive lint buildup inside the unit, use errors.Manufacture date is not known.H3 other text : 81.
Event or Problem Description
It was reported that there was loss of light.

• Brand Name: L9000 LIGHTSOURCE INTERNATIONAL KIT
• Common Device Name: LIGHT SOURCE, FIBEROPTIC, ROUTINE
• Manufacturer (Section D): STRYKER ENDOSCOPY-SAN JOSE; 5900 optical court; san jose CA 95138
• MDR Report Key: 12315309
• Report Number: 0002936485-2021-00424
• Device Sequence Number: 3937271
• Product Code: FCW
• UDI-Device Identifier: 07613327051339
• UDI-Public: 07613327051339
• Combination Product (Y/N): N
• Initial Reporter Country: FR
• PMA/510(K) Number: K082813
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Biomedical Engineer
• Type of Report: Initial,Followup
• Report Date (Section B): 09/23/2021

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 Number: 0220210000
• Device Catalogue Number: 0220210000I
• Device Lot Number: 15L004844
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 07/15/2021
• Supplement Date Received by Manufacturer: 07/15/2021
• Initial Report FDA Received Date: 08/12/2021
• Supplement Report FDA Received Date: 09/23/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1