MAUDE Adverse Event Report: OLYMPUS MEDICAL SYSTEMS CORP. DISPOSABLE GRASPING FORCEPS(PARALLEL BASKET TYPE,3FR.)

Model Number	FG-51D
Medical Device Problem Code	Mechanical Problem (1384)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	04/03/2022
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The device referenced in this report has not been returned to olympus for evaluation.The investigation is ongoing.The definitive cause of the user¿s experience cannot be determined at this time.A supplemental report will be submitted upon completion of the investigation or if any additional information is provided by the user facility.
Event or Problem Description
A user facility reported to olympus, the disposable grasping forceps (parallel basket type,3fr.) was opening but did not close.The event occurred during an unknown therapeutic procedure.It was reported the issue occurred twice, and the suspected device was replaced.There were no reports of patient harm associated with this event.This complaint is related to patient identifier (b)(6) (first event).
Additional Manufacturer Narrative
This report is being supplemented to provide additional information based on the legal manufacturer's evaluation and final investigation.The results of evaluation determined that the outer sheath was damaged/kinked, and was torn near the black tube.The grasping portion was unable to extract from the tube by pushing the ring.It was unable to open.When the ring was operated by holding the broken area after the tube was straightened, the grasping portion was able to open and close.A review of the device history record found no deviations that could have caused or contributed to the reported issue.Based on the results of the investigation, a definitive root cause could not be established.The suggested phenomenon was presumed to have been due to either "the products did not meet the specifications" or "device handling".If the reported event was caused by "a product that did not meet the specifications", a likely mechanism causing the reported event might be the following: 1.A force to open and close the basket was greater than the standard value.Therefore, a compression force was applied to the tube when operating (open/close) the basket.2.The tube was buckled compressively near the black tube.3.Repeatedly operating the ring made the compressively buckled part to stretch and tear.4.Due to compressive buckling or breakage of the tube, the basket could not be opened.If the reported event was caused by device handling, a likely mechanism causing the reported event might be the following: 1.The details surrounding the event were not determined.However, the tube was bent at an acute angle.2.The ring was operated under circumstances described above.Therefore, a sliding resistance between the tube and operation wire increased causing compressive buckling of the tube.3.Repeatedly operating the ring made the compressively buckled part to stretch and tear.4.Due to compressive buckling or breakage of the tube, the basket could not be opened.The instructions for use (ifu) contains the following information: "do not coil the insertion portion with a diameter of less than 15 cm.This could damage the insertion portion.Never use excessive force to open or close the grasping portion.This could damage the instrument.When the grasping portion does not open and/or close smoothly, do not apply force but set the scope¿s angle back, or move the position of the grasping portion until the basket opens and closes smoothly.If the action is forced, the tube may stretch and the resistance of the handle may increase.Also the calculus may not be retrieved, and/or the grasping portion with calculus engaged may not be removed from the body." olympus will continue to monitor field performance for this device.

• Brand Name: DISPOSABLE GRASPING FORCEPS(PARALLEL BASKET TYPE,3FR.)
• Common Device Name: DISPOSABLE GRASPING FORCEPS
• 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: 14286819
• Report Number: 8010047-2022-07595
• Device Sequence Number: 1559132
• Product Code: PTS
• UDI-Device Identifier: 04953170060564
• UDI-Public: 04953170060564
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: CLASS1-EXMPT
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Other,Foreign,Health Professional,User Facility
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 08/17/2022

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: FG-51D
• Device Lot Number: 17K
• Was Device Available for Evaluation?: Yes
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/05/2022
• Supplement Date Received by Manufacturer: 07/21/2022
• Initial Report FDA Received Date: 05/05/2022
• Supplement Report FDA Received Date: 08/17/2022
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 07/01/2021
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• If action reported to FDA under 21 USC 360i(g), list FDA-assigned Recall Number or include a statement: Z-1122-2022
• Patient Sequence Number: 1
• Patient Sex: Unknown