MAUDE Adverse Event Report: VENTEC LIFE SYSTEMS, INC VOCSN; VENTILATOR, CONTINUOUS, FACILITY USE

Model Number	V+C, JAPANESE
Medical Device Problem Code	Unexpected Shutdown (4019)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	06/13/2024
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Corrected information for supplemental medwatch report 001 -- section d4, model #, of the initial medwatch report stated: prt-01098-100.Section d4, model #, of the initial medwatch report should have stated: v+c, japanese.Section d4, udi #, of the initial medwatch report stated: (b)(4).Section d4, udi #, of the initial medwatch report should have stated: (b)(4).New information for supplemental medwatch report 001 -- h6: the device was evaluated by ventec where the reported issue of it rebooting by itself was confirmed.Ventec opened the device to perform an internal inspection and observed that the device's cough assist valve had a torn poppet ring.Ventec replaced the cough assist valve to resolve the reported issue.Proper device operation was then confirmed through functional and performance testing.The investigation determined that the root cause of the reported issue was the cough assist valve's poppet ring was torn.
Additional Manufacturer Narrative
H6: the asp elected to return the device to ventec.Ventec will perform an evaluation of the device.A follow-up report will be submitted when the investigation is complete as defined by 21 cfr 803.56.
Event or Problem Description
An authorized third party service provider (asp) contacted ventec to report that the device allegedly began rebooting by itself during use.There was patient involvement associated with the reported event; however, there were no reports of patient harm as a result of the reported issue.No further details about the patient were provided.Ventec has reached out to the asp in order to obtain additional information about the patient, but no response has been received.

• Brand Name: VOCSN
• Common Device Name: VENTILATOR, CONTINUOUS, FACILITY USE
• Manufacturer (Section D): VENTEC LIFE SYSTEMS, INC; 22002 26th ave se; bothell WA 98021
• Manufacturer (Section G): VENTEC LIFE SYSTEMS, INC; 22002 26th ave se; bothell WA 98021
• Manufacturer Contact: elizabeth gilbert ; 22002 26th ave se; bothell, WA 98021 ; 4256861765
• MDR Report Key: 19698028
• Report Number: 3013095415-2024-00505
• Device Sequence Number: 11685283
• Product Code: CBK
• UDI-Device Identifier: 00850018761116
• UDI-Public: (01)00850018761116(11)210224
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K162877
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Other,Foreign
• Initial Reporter Occupation: 505
• Type of Report: Initial,Followup
• Report Date (Section B): 06/13/2024

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: V+C, JAPANESE
• Device Catalogue Number: PRT-01098-100
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 06/24/2024
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 06/13/2024
• Supplement Date Received by Manufacturer: 07/14/2024
• Initial Report FDA Received Date: 07/08/2024
• Supplement Report FDA Received Date: 08/11/2024
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 02/24/2021
• 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: Unknown
• Patient Sequence Number: 1
• Patient Sex: Unknown