MAUDE Adverse Event Report: STRYKER ENDOSCOPY-SAN JOSE PKG, IDEAL EYES ZOOM COUPLER, C-MOUNT; LAPAROSCOPE, GENERAL & PLASTIC SURGERY

Model Number	1488020125
Medical Device Problem Code	Optical Distortion (3000)
Health Effect - Clinical Codes	Insufficient Information (4580); No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	07/04/2022
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that there was blurry image.The original device could not be used to complete the procedure.
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.
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.Alleged failure: can't focus.Probable root cause: manufacturing/service nonconformity.Scratches / dents.Loose connections / gaps.Rough / chipping surfaces.Damage during cleaning.Use error.The reported failure mode will be monitored for future reoccurrence.
Event or Problem Description
It was reported that there was blurry image.The original device could not be used to complete the procedure.

• Brand Name: PKG, IDEAL EYES ZOOM COUPLER, C-MOUNT
• Common Device Name: LAPAROSCOPE, GENERAL & PLASTIC SURGERY
• Manufacturer (Section D): STRYKER ENDOSCOPY-SAN JOSE; 5900 optical court; san jose CA 95138
• Manufacturer (Section G): STRYKER ENDOSCOPY-SAN JOSE; 5900 optical court; san jose CA 95138
• Manufacturer Contact: benjamin ly ; 5900 optical court; san jose, CA 95138 ; 4087542000
• MDR Report Key: 15083615
• Report Number: 0002936485-2022-00421
• Device Sequence Number: 14714532
• Product Code: GCJ
• UDI-Device Identifier: 07613327061086
• UDI-Public: 07613327061086
• Combination Product (Y/N): N
• Initial Reporter Country: CH
• PMA/510(K) Number: K132785
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 10/03/2022

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: 1488020125
• Device Catalogue Number: 1488020125
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 07/05/2022
• Supplement Date Received by Manufacturer: 07/05/2022
• Initial Report FDA Received Date: 07/22/2022
• Supplement Report FDA Received Date: 10/03/2022
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 11/01/2016
• Is the Device Labeled for Single Use? (Y/N): No
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Reuse
• Patient Sequence Number: 1
• Patient Sex: Unknown