MAUDE Adverse Event Report: QUANTA SYSTEM S.P.A. CYBER; SURGICAL LASER

Catalog Number	PUMS00009
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	05/26/2017
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The problem was due to a component failure.We are unaware about patient injury.We are waiting for additional information from distributor.
Event or Problem Description
The laser system had a failure that did not allow to use it.No adverse effects to patient were reported.
Additional Manufacturer Narrative
The problem was due to a component failure.We are unaware about patient injury.
Event or Problem Description
The laser system had a failure that did not allow to use it.No adverse effects to patient were reported.

• Brand Name: CYBER
• Common Device Name: SURGICAL LASER
• Manufacturer (Section D): QUANTA SYSTEM S.P.A.; via acquedotto, 109; samarate, varese 21017 ; IT 21017
• MDR Report Key: 6700124
• Report Number: 3004378299-2017-00033
• Device Sequence Number: 16607700
• Product Code: GEX
• UDI-Device Identifier: 08033945934804
• UDI-Public: 08033945934804
• Combination Product (Y/N): N
• Initial Reporter State: OR
• Initial Reporter Country: US
• PMA/510(K) Number: K131081
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: distributor
• Initial Reporter Occupation: Other
• Remedial Action: Repair,Inspection
• Type of Report: Initial,Followup
• Report Date (Section B): 10/12/2017

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: No Information
• Device Catalogue Number: PUMS00009
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Initial Date Received by Manufacturer: 06/13/2017
• Supplement Date Received by Manufacturer: 06/13/2017
• Initial Report FDA Received Date: 07/11/2017
• Supplement Report FDA Received Date: 10/13/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1