MAUDE Adverse Event Report: AIZU OLYMPUS CO., LTD. EVIS EXERA BRONCHOVIDEOSCOPE

Model Number	BF-XT160
Medical Device Problem Code	No Display/Image (1183)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	12/01/2023
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The device was returned as part of the asset return process, other findings includes no data from exera id data verification; scope leak test shows leaking from the bending section cover, the bending section cover is leaking due to a cut; and, the insertion tube is crushed.The investigation is ongoing, and a supplemental report will be submitted upon completion of the investigation or if any additional information is provided.
Event or Problem Description
A user facility returned the olympus asset, bronchovideoscope, to the olympus service center with a description of "broken".Upon inspection and testing of the returned device, it was observed that there was no image (black).This report is being submitted for the event found during evaluation.There was no patient involvement.
Additional Manufacturer Narrative
This report is being supplemented to provide additional information based on the device evaluation and the legal manufacturer's final investigation.New information added to the following fields: h6.A review of device history record and historical complaints analysis was conducted and no deviations that could have caused or contributed to the reported issues was identified.During the evaluation the event reported was confirmed.Based on the results of the investigation a definitive root cause could not be determined.However, based on the results of the investigations, while the user was handling the device, physical stress was applied to the bending section cover which led to abnormality of electronic parts.As a result, the no image event occurred.The event can be prevented by following the instructions for use which state: important information - please read before use.Precaution for disappeared or frozen endoscopic image; warning: follow the precautions given below when handling the instrument.Otherwise, the endoscopic image may disappear unexpectedly, or the frozen image may not be restored during the evaluation.Precaution for disappeared or frozen endoscopic image; caution: turn the video system center off before connecting or disconnecting the videoscope cable from electrical connector on the endoscope.Turn the switch on or off only when the videoscope cable is connected to both the video system center and electrical connector of the endoscope.Failure to do so can result in equipment damage, including destructions of the charged coupled device.Do not touch the electrical contacts inside the electrical connector.Charged coupled device damage may result.3.6 inspection of the endoscopic system.Inspection of the endoscopic image.While observing the palm of your hand, confirm the wli and nbi endoscopic image is free from noise, blur, fog, or other irregularities.Angulate the bending section and confirm the endoscopic image is free from momentary disappearing or other irregularities.Chapter 5.Troubleshooting: if the endoscope is visibly damaged, does not function as expected or is found to have irregularities during the inspection described in chapter 3, ''preparation and inspection'', do not use the endoscope.Contact olympus.Some problems that appear to be malfunctions may be correctable by referring to section 5.1 ''troubleshooting guide''.If the problem cannot be resolved by the described remedial action, stop using the endoscope and send it to olympus for repair.Olympus does not repair accessory parts.If an accessory part becomes damaged, contact olympus to purchase a replacement.Olympus will continue to monitor field performance for this device.

• Brand Name: EVIS EXERA BRONCHOVIDEOSCOPE
• Common Device Name: BRONCHOVIDEOSCOPE
• Manufacturer (Section D): AIZU OLYMPUS CO., LTD.; 3-1-1 niiderakita; aizuwakamatsu-shi, fukushima 965-8 520; JA 965-8520
• Manufacturer (Section G): AIZU OLYMPUS CO., LTD.; 3-1-1 niiderakita; aizuwakamatsu-shi, fukushima
• Manufacturer Contact: todd brill ; 800 west park drive; westborough, MA 01581 ; 5082077661
• MDR Report Key: 18380202
• Report Number: 9610595-2023-20071
• Device Sequence Number: 20727854
• Product Code: EOQ
• UDI-Device Identifier: 04953170340147
• UDI-Public: 04953170340147
• Combination Product (Y/N): N
• Initial Reporter State: OH
• Initial Reporter Country: US
• PMA/510(K) Number: K023984
• 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: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 01/23/2024

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: BF-XT160
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 12/15/2023
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 12/18/2023
• Supplement Date Received by Manufacturer: 01/11/2024
• Initial Report FDA Received Date: 12/21/2023
• Supplement Report FDA Received Date: 01/23/2024
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 01/20/2005
• 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