MAUDE Adverse Event Report: OLYMPUS WINTER & IBE GMBH OUTER SHEATH, 22.5 FR.; RIGID ENDOSCOPE SHEATH

Model Number	WA22810A
Medical Device Problem Code	Thermal Decomposition of Device (1071)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The evaluation of the event is ongoing.Should additional relevant information become available, a supplemental report will be submitted.
Event or Problem Description
It was reported the rigid endoscope sheath's distal tip was burnt.There were no reports of patient harm.
Additional Manufacturer Narrative
This supplemental report is being submitted to provide the results of the legal manufacturer's final investigation.The device history record was unable to be reviewed for this device since the lot number was not provided.However, olympus only releases products to market that meet all manufacturing specifications and final product release criteria.Based on the results of the investigation and as the device was not returned to olympus, root cause of the reported issue cannot be determined.The malfunction caused was most likely due to wrong handling / improper handling on the part of the user.Additionally, the user may have drawn the activated laser probe into the sheath or activated the laser probe in the sheath, which is contrary to the instruction for use.The event can be detected/prevented by following the instructions which states: note when the laser fiber¿s guiding pin within the adapter¿s narrow groove faces downwards, the laser beam will be emitted from the underside of the laser fiber.Caution risk of damaging the inner sheath the inner sheath¿s distal end may be damaged if the laser fiber¿s tip is retracted into the sheath too early.To minimize this risk, use the adapter wa22870a together with a compatible laser fiber.Danger risk of death or serious injury improper use of lasers can cause burns, eye damage, and explosions.Thoroughly review the laser safety information included in the system guide endoscopy.Olympus will continue to monitor field performance for this device.
Event or Problem Description
The issue was found during reprocessing for a therapeutic laser vaporization of prostate procedure.The intended procedure was completed and there was no delay.

• Brand Name: OUTER SHEATH, 22.5 FR.
• Common Device Name: RIGID ENDOSCOPE SHEATH
• Manufacturer (Section D): OLYMPUS WINTER & IBE GMBH; kuehnstrasse 61; hamburg, hamburg 22045 ; GM 22045
• Manufacturer (Section G): OLYMPUS WINTER & IBE GMBH; kuehnstrasse 61; hamburg, hamburg
• Manufacturer Contact: todd brill ; 800 west park drive; westborough, MA 01581 ; 5082077661
• MDR Report Key: 18979464
• Report Number: 9610773-2024-00864
• Device Sequence Number: 12320522
• Product Code: GCP
• UDI-Device Identifier: 04042761051729
• UDI-Public: 04042761051729
• Combination Product (Y/N): N
• Initial Reporter State: AZ
• Initial Reporter Country: US
• PMA/510(K) Number: K790071
• 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: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 04/24/2024

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: WA22810A
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: No
• 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: 03/14/2024
• Supplement Date Received by Manufacturer: 04/16/2024
• Initial Report FDA Received Date: 03/26/2024
• Supplement Report FDA Received Date: 04/24/2024
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• 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