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

Model Number	106369
Medical Device Problem Code	Insufficient Device Problem Information (3190)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	04/22/2026
Type of Reportable Event	Malfunction
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.The device was not returned and the lot number is unknown; therefore, a device analysis could not be completed.Although the reported event did not result in a serious injury, the report of a damaged power supply, were it to have exposed copper wires could potentially contribute to a serious injury or death, if the malfunction were to recur.Therefore, baxter considers this complaint a reportable malfunction.
Event or Problem Description
The customer reported the power supply was damaged.There was no patient/user injury reported.This report was filed in our complaint handling system as complaint # (b)(4).

• Brand Name: VS100 POWER SUPPLY SET/PLUGB/US
• Common Device Name: REFRACTOMETER, OPHTHALMIC
• Manufacturer (Section D): WELCH ALLYN INC; 4341 state street; skaneateles falls NY 13153
• Manufacturer Contact: mauricio cerecer ; 1069 state route 46 east; batesville, IN 47006
• MDR Report Key: 25194059
• Report Number: 1316463-2026-00040
• Device Sequence Number: 10096774
• Product Code: HKO
• UDI-Device Identifier: 00732094212235
• UDI-Public: (01)00732094212235
• Combination Product (Y/N): N
• Initial Reporter State: OH
• 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,Followup
• Report Date (Section B): 06/23/2026

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?: No
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/22/2026
• Supplement Date Received by Manufacturer: 06/05/2026
• Initial Report FDA Received Date: 05/15/2026
• Supplement Report FDA Received Date: 06/24/2026
• Was Device Evaluated by Manufacturer? (Y/N): No
• 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