MAUDE Adverse Event Report: AIZU OLYMPUS CO., LTD. WASHING CASE

Model Number	MAJ-2121
Medical Device Problem Code	Device Reprocessing Problem (1091)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	06/06/2023
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The device was not returned to olympus for evaluation as the field service engineer (fse) was at the facility.The investigation is ongoing.A supplemental report will be submitted upon completion of the investigation.
Event or Problem Description
The field service engineer (fse) reported to olympus, the washing case was being used off label.Field service engineer (fse) arrived at the customer's facility and noticed that the washing basin lids were removed from the washing basin cup, fse reattached 3 out of 4 washing basin lids and the customer could not find the 4th lid and will be looking for the lid.There were no reports of patient involvement.
Additional Manufacturer Narrative
This report is being supplemented to provide additional information based on the legal manufacturer's final investigation.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, the definitive root cause of the washing case issue could not be determined.It is possible that when the user opened the lid of the washing case, unexpected force was applied such as pulling the chain at the black rubber or pushing the rubber obliquely and laterally, which caused the event.Once the rubber was detached, the lid may not have attached properly to the rubber, then was easily detached.Use of the lid without proper attachment of the rubber would cause the lid detached.The instruction manual identifies the following verbiage, which may have prevented the phenomenon: ¿make sure that the washing case (with a gray cover) for exclusive use with this reprocessor is attached.Also, check that the washing case is free of irregularity such as a crack or fissure.If any irregularity is found, do not use the washing case and contact olympus.¿ olympus will continue to monitor field performance for this device.
Additional Manufacturer Narrative
This report is being submitted to correct the legal manufacturer¿s contact information and facility registration number.The facility registration number is 9610595.The device was returned to olympus for inspection, and the reportable malfunction was confirmed.The gray plastic lid of the washing case had signs of several scratches on the top of the lid.In addition, the bottom of the gray lid contained scratches and rough edges on the sides of the six gray plastic portions sticking out.Olympus will continue to monitor the field performance of this device.Should additional relevant information become available, a supplemental report will be submitted.

• Brand Name: WASHING CASE
• Common Device Name: WASHING CASE
• Manufacturer (Section D): AIZU OLYMPUS CO., LTD.; 3-1-1 niiderakita; odakura, nishigo-mura,; aizuwakamatsu-shi, fukushima 965-8 520; JA 965-8520
• Manufacturer (Section G): AIZU OLYMPUS CO., LTD.; 3-1-1 niiderakita; odakura, nishigo-mura,; aizuwakamatsu-shi, fukushima 965-8 520; JA 965-8520
• Manufacturer Contact: todd brill ; 800 west park drive; westborough, MA 01581 ; 5082077661
• MDR Report Key: 17222921
• Report Number: 3002808148-2023-06529
• Device Sequence Number: 7097905
• Product Code: FEB
• UDI-Device Identifier: 04953170404153
• UDI-Public: 04953170404153
• Combination Product (Y/N): N
• Initial Reporter State: AZ
• Initial Reporter Country: US
• PMA/510(K) Number: K190969
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: User Facility,Company Representative
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 05/15/2024

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: MAJ-2121
• Device Lot Number: 27A
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 06/06/2023
• Supplement Date Received by Manufacturer: 08/04/2023; 05/14/2024
• Initial Report FDA Received Date: 06/29/2023
• Supplement Report FDA Received Date: 08/25/2023; 05/15/2024
• 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
• Usage of Device: Reuse
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: OER-ELITE - REPROCESSOR
• Patient Sex: Unknown