MAUDE Adverse Event Report: HOYA CORPORATION PENTAX TOKYO OFFICE PENTAX; FIBEROPTIC BRONCHOSCOPE 3.2C 6.2TP 600L

Model Number	FB-19TV
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	09/16/2022
Type of Reportable Event	Malfunction
Event or Problem Description
The time of event is unknown.There was no report of patient harm.Fiber image failure(broken).
Additional Manufacturer Narrative
This device is classified as import for export, therefore 510k is not applicable.Model fb-15v is available in the usa with a 510k number k951199.We checked the returned unit and confirmed that the image guide fiber bundle (cfb) broken.Based on the result, we concluded that it was caused due to the excessive force applied on the image guide fiber bundle (cfb).In addition, we confirmed that the angle wire fluid damage, the control body fluid damage, the forward body frame fluid damage, the light guide fiber bundle (lcb) broken, the insertion flexible tube (ift) perforated, the ift buckled, the control body corroded, the forward body frame corroded, the ift crushed, the segment crushed, the ift leak, the light guide cable disinfections damage, the operation channel resistance, the angle wire grinding, the angulation-down angulation decrease, and the angulation-up angulation decrease; however, they are not the main cause, and/or irrelevant to the alleged complaint.Based on the technical report hr-rpt-0586(image failure) and/or the risk analysis results, it was evaluated to submit mdr.

• Brand Name: PENTAX
• Common Device Name: FIBEROPTIC BRONCHOSCOPE 3.2C 6.2TP 600L
• Manufacturer (Section D): HOYA CORPORATION PENTAX TOKYO OFFICE; tsutsujigaoka 1-1-110; akishisima-shi, tokyo 196-0 012; JA 196-0012
• Manufacturer (Section G): HOYA CORPORATION PENTAX TOKYO OFFICE; tsutsujigaoka 1-1-110; akishisima-shi, tokyo 196-0 012; JA 196-0012
• Manufacturer Contact: william goeller ; 3 paragon drive; montvale, NJ 07645
• MDR Report Key: 15516195
• Report Number: 9610877-2022-58345
• Device Sequence Number: 2533195
• Product Code: EOQ
• UDI-Device Identifier: 04961333083534
• UDI-Public: 04961333083534
• Combination Product (Y/N): N
• Initial Reporter Country: CS
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Foreign,Distributor
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 09/30/2022

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: FB-19TV
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 09/16/2022
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 09/16/2022
• Initial Report FDA Received Date: 09/30/2022
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• 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
• Patient Sequence Number: 1
• Patient Sex: Unknown