MAUDE Adverse Event Report: AIZU OLYMPUS CO., LTD. EVIS GASTROINTESTINAL VIDEOSCOPE

Model Number	GIF-2T100
Medical Device Problem Code	Device Reprocessing Problem (1091)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	11/29/2023
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The suspect device will not be returned to olympus for evaluation.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, as the device was not returned, the root cause of the reported event is unable to be determined.However, it is presumable that the reported event is due to the user not following the instructions for use (ifu) which caused them to use the expired water filter passed the replacement period.The suggested event can be prevented by handling the device in accordance with the ifu: "chapter 7 routine maintenance 7.2 replacing the water filter (maj-824) replace the water filter at least once a month to prevent contamination of the rinse water.The water filter should also be replaced whenever an error code indicating water supply insufficiency [e01] is displayed.The water filter should be replaced by following the flow shown below." olympus will continue to monitor field performance for this device.
Event or Problem Description
It was reported that the subject device had been reprocessed with an endoscope reprocessor in which the water filter replacement deadline had expired by two years.There were no reports of patient harm.

• Brand Name: EVIS GASTROINTESTINAL VIDEOSCOPE
• Common Device Name: GASTROINTESTINAL VIDEOSCOPE
• 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 965-8 520; JA 965-8520
• Manufacturer Contact: todd brill ; 800 west park drive; westborough, MA 01581 ; 5082077661
• MDR Report Key: 19237118
• Report Number: 9610595-2024-09117
• Device Sequence Number: 18148007
• Product Code: FDS
• UDI-Device Identifier: 00724995091583
• UDI-Public: 00724995091583
• Combination Product (Y/N): N
• Initial Reporter Country: EC
• PMA/510(K) Number: K954451
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,User Facility,Company Representative,Distributor
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 05/03/2024

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: GIF-2T100
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 01/04/2024
• Initial Report FDA Received Date: 05/03/2024
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 01/23/2019
• 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