MAUDE Adverse Event Report: AOMORI OLYMPUS CO., LTD. SINGLE USE ASPIRATION NEEDLE NA-U200H

Model Number	NA-U200H-8019
Medical Device Problem Code	Fracture (1260)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	11/01/2024
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The investigation is ongoing.A supplemental report will be submitted when the investigation is completed or if additional information becomes available.
Event or Problem Description
It was reported that during a endoscopic ultrasound-guided gallbladder drainage therapeutic procedure, the needle broke off and was discovered on the floor.The needle was discarded and the procedure was completed utilizing an olympus back-up device.There were no reports of patient harm.
Event or Problem Description
It was reported that during a endoscopic ultrasound-guided gallbladder drainage therapeutic procedure, the needle broke off and was discovered on the floor.The needle was discarded and the procedure was completed utilizing an olympus back-up device.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 was returned to olympus for inspection and the reported failure was confirmed.A definitive root cause could not be identified.Based on the results of the investigation, it is likely the following led to the malfunction: bending load applied to the needle causing it to break.Should additional relevant information become available, a supplemental report will be submitted.Olympus will continue to monitor field performance for this device.
Additional Manufacturer Narrative
This supplemental emdr is being submitted to correct the manufacturing date: h4.
Event or Problem Description
It was reported that during a endoscopic ultrasound-guided gallbladder drainage therapeutic procedure, the needle broke off and was discovered on the floor.The needle was discarded and the procedure was completed utilizing an olympus back-up device.There were no reports of patient harm.
Additional Manufacturer Narrative
This supplemental emdr is being submitted to correct the manufacturing date: 6/1/2024 h4.
Event or Problem Description
It was reported that during a endoscopic ultrasound-guided gallbladder drainage therapeutic procedure, the needle broke off and was discovered on the floor.The needle was discarded and the procedure was completed utilizing an olympus back-up device.There were no reports of patient harm.

• Brand Name: SINGLE USE ASPIRATION NEEDLE NA-U200H
• Common Device Name: SINGLE USE ASPIRATION NEEDLE
• Manufacturer (Section D): AOMORI OLYMPUS CO., LTD.; 2-248-1 okkonoki; kuroishi-shi, aomori 036-0 357; JA 036-0357
• Manufacturer (Section G): AOMORI OLYMPUS CO., LTD.; 2-248-1 okkonoki; kuroishi-shi, aomori 036-0 357; JA 036-0357
• Manufacturer Contact: todd brill ; 800 west park drive; westborough, MA 01581 ; 5082077661
• MDR Report Key: 20833688
• Report Number: 9614641-2024-20037
• Device Sequence Number: 8638684
• Product Code: FCG
• UDI-Device Identifier: 04953170380402
• UDI-Public: 04953170380402
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K180449
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,User Facility
• Initial Reporter Occupation: Nurse
• Type of Report: Initial,Followup,Followup,Followup
• Report Date (Section B): 04/15/2025

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: NA-U200H-8019
• Device Lot Number: 46K
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 11/05/2024
• Supplement Date Received by Manufacturer: 12/10/2024; 04/11/2025; 04/11/2025
• Initial Report FDA Received Date: 12/03/2024
• Supplement Report FDA Received Date: 01/07/2025; 04/11/2025; 04/15/2025
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 06/01/2024
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Patient Sex: Unknown