MAUDE Adverse Event Report: AOMORI OLYMPUS CO., LTD. SINGLE USE ROTATABLE CLIP FIXING DEVICE

Model Number	HX-201UR-135-A
Medical Device Problem Codes	Separation Failure (2547); Activation, Positioning or Separation Problem (2906)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	07/01/2022
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The customer returned 3 single use rotatable clip fixing device model number hx-201ur-135-a , lot number 17v 01 for the evaluation ¿quick clips would attach to tissue but would not detach from the wire.Out of box failure.¿ these three (3) returned devices noted that - ( one device , the clip on the device has been deployed , the other two devices, clip still attached ).A visual and functional inspection on the as is received condition of the devices performed.There are no sharp protrusions or edges on the distal end of the insertion portion of these devices.The entire length of each insertion portion inspected and verified there were no crushed, bends, or broken areas.The handle portion appears to have no cracks or discrepancies.Unable to perform any functional tests on this device as the clip was deployed and not returned for evaluation - this is for the device where the clip has been deployed and not returned for evaluation.Investigation is ongoing.This report will be supplemented accordingly following investigation.
Event or Problem Description
Customer reported an out of box failures for three hx-201ur-135-a device with lot number 17v 01.Device was reported to fail upon initial use (therapeutic).The quickclips would attach to tissue, but would not detach from the wire.There was no patient harm or injury reported due to the event.No user injury reported.This event includes three (3) reports to account the three devices failed that customer reported.Report with patient identifier (b)(6).Report with patient identifier (b)(6).Report with patient identifier (b)(6).This report is for patient identifier (b)(6).
Additional Manufacturer Narrative
This report is being supplemented to provide additional information based on the approved final investigation.A review of the device history record found no deviations that could have caused or contributed to the reported issue.The device was manufactured in july 2021.However, the specific date is unknown.Based on the results of the investigation, the definitive root cause of the detachment issue could not be determined.It is possible that a tensile force beyond the resistance strength was applied to the area where the wire was secured in place, which caused the wire to detach from the operating portion.It is also possible that the clip was pressed against an object, which increased the slider's sliding resistance.The instruction manual identifies the following verbiage, which may have prevented the phenomenon: ¿should the slightest irregularity and/or breakage of the parts be suspected, withdraw the instrument from the endoscope immediately according to the steps of ¿withdrawing the instrument from the endoscope¿ on page 10.Otherwise, perforation, bleeding, or mucous membrane damage may result.¿ olympus will continue to monitor field performance for this device.

• Brand Name: SINGLE USE ROTATABLE CLIP FIXING DEVICE
• Common Device Name: SINGLE USE ROTATABLE CLIP FIXING DEVICE
• Manufacturer (Section D): AOMORI OLYMPUS CO., LTD.; 2-248-1 okkonoki; kuroishi-shi, aomori 036-0 357; JA 036-0357
• Manufacturer Contact: masaharu hirose ; 2-248-1 okkonoki; kuroishi-shi, aomori 036-0-357 ; JA 036-0357 ; 426422891
• MDR Report Key: 15161603
• Report Number: 9614641-2022-00099
• Device Sequence Number: 6167280
• Product Code: MND
• UDI-Device Identifier: 04953170353123
• UDI-Public: 04953170353123
• Combination Product (Y/N): N
• Initial Reporter State: WA
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Health Professional,User Facility
• Initial Reporter Occupation: Administrator/Supervisor
• Type of Report: Initial,Followup
• Report Date (Section B): 10/21/2022

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: HX-201UR-135-A
• Device Lot Number: 17V 01
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 07/25/2022
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 07/06/2022
• Supplement Date Received by Manufacturer: 09/22/2022
• Initial Report FDA Received Date: 08/03/2022
• Supplement Report FDA Received Date: 10/21/2022
• 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
• Patient Sequence Number: 1
• Patient Sex: Unknown