MAUDE Adverse Event Report: WELSH ALLYN INC VS100 POWER SUPPLY SET/PLUGB/US; REFRACTOMETER, OPHTHALMIC

Model Number	106369
Medical Device Problem Codes	Sparking (2595); Material Split, Cut or Torn (4008)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	03/28/2025
Type of Reportable Event	Malfunction
Event or Problem Description
Customer reported physical damage.Wiring on the power supply was exposed between the adaptor box and the plug into the device and was sparking.There was no injury reported.This incident was captured under hillrom complaint ref # (b)(4).
Additional Manufacturer Narrative
The spot vs100 is intended for vision screening of subjects from the age of 6 months through adults.The device evaluates a subject¿s refraction, pupil size and visual gaze for determining the need for referral to for further evaluation.A medical (vision) professional.Spot vs100 is indicated for use when evaluation of individuals for poor vision and refractive errors is needed.Although there was no reported injury with this event, if the report of wiring on the power supply was exposed and sparking were to recur, it could potentially cause serious injury or death.Therefore baxter is reporting this event.

• Brand Name: VS100 POWER SUPPLY SET/PLUGB/US
• Common Device Name: REFRACTOMETER, OPHTHALMIC
• Manufacturer (Section D): WELSH ALLYN INC; 4341 state street; skaneateles falls NY 13153
• Manufacturer Contact: frances coote ; 1069 state route 46 east; batesville, IN 47006 ; 8129310130
• MDR Report Key: 21761326
• Report Number: 1316463-2025-00038
• Device Sequence Number: 8463401
• Product Code: HKO
• UDI-Device Identifier: 00732094212228
• UDI-Public: 732094212228
• Combination Product (Y/N): N
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: User Facility
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 04/03/2025

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
• Device Model Number: 106369
• Was Device Available for Evaluation?: Yes
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/28/2025
• Initial Report FDA Received Date: 04/03/2025
• 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