MAUDE Adverse Event Report: OLYMPUS MEDICAL SYSTEMS CORP. SINGLE USE 3-LUMEN NEEDLE KNIFE V

Model Number KD-V441M

Device Problem Break (1069)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Date 10/18/2021

Event Type  malfunction  

Manufacturer Narrative

The suspect device has been returned for evaluation and the investigation is in progress.The subject device was returned for evaluation and it was found the wire was broken with energization.Once the investigation has been completed, a supplemental report will be submitted with device evaluation results.

Event Description

The customer reported the tip of the kd broke off and was stuck in the papilla.The intended endoscopic retrograde cholangiopancreatography procedure was successfully completed using a tjf endoscope.There was an unspecified procedure delay due to removing the broken segment from the papilla.No patient harm or injury reported.The erbe hf device was normal kd settings.No additional information is available.The device was returned for repair.The olympus service center identified the wire was broken with energization.This is a reportable event.

Manufacturer Narrative

This report is being supplemented to provide additional information based on the legal manufacturer's investigation.A review of the device history record found no deviations that could have caused or contributed to the reported issue.It has been over 1 year since the subject device was manufactured.Based on the results of the legal manufacturer's investigation, the root cause of the broken knife wire could not be identified.Olympus will continue to monitor field performance for this device.

Manufacturer Narrative

Correction to g3 of the initial medwatch.The aware date should be (b)(6) 2021.Investigation activities have been opened, to manage the actions related to this report and any required mdr reporting.

• Brand Name: SINGLE USE 3-LUMEN NEEDLE KNIFE V
• Type of Device: SINGLE USE 3-LUMEN NEEDLE KNIFE
• Manufacturer (Section D): OLYMPUS MEDICAL SYSTEMS CORP.; 2951 ishikawa-cho; hachioji-shi, tokyo-to 192-8 507; JA 192-8507
• Manufacturer Contact: kazutaka matsumoto ; 2951 ishikawa-cho; hachioji-shi, tokyo-to 192-8-507 ; JA 192-8507 ; 426425177
• MDR Report Key: 13122382
• MDR Text Key: 284871402
• Report Number: 8010047-2021-16988
• Device Sequence Number: 1
• Product Code: KNS
• UDI-Device Identifier: 04953170382703
• UDI-Public: 04953170382703
• Combination Product (y/n): N
• Reporter Country Code: GM
• PMA/PMN Number: K955247
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Other,Foreign,Health Professional,User Facility,Company Representative
• Reporter Occupation: Other
• Type of Report: Initial,Followup,Followup
• Report Date: 12/06/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 12/30/2021
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: KD-V441M
• Device Lot Number: 11K
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/03/2021
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: No
• Date Manufacturer Received: 11/08/2022
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 01/13/2021
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Unknown
• Patient Sequence Number: 1
• Treatment: ERBE HF DEVICE