MAUDE Adverse Event Report: REFURBISHED SITE~RITE 6 ULTRASOUND SYSTEM PROBE; SYSTEM, IMAGING, PULSED ECHO, ULTRASONIC

Model Number	9770001R
Medical Device Problem Code	Poor Quality Image (1408)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The manufacturer has received the sample and will be evaluated.A supplemental will be submitted with evaluation results.A history review of serial number (b)(4) showed no other similar product complaint(s) from this serial number.
Event or Problem Description
The probe was visually inspected upon receipt and was found to have poor image.
Additional Manufacturer Narrative
H11: section a through f - the information provided by bd represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to bd.The following were reviewed as part of this investigation: patient severity, applicable previous investigation(s), sample (if available), applicable fmea documents, labeling, and applicable manufacture records.Based on a review of this information, the following was concluded: the device was returned with no alleged deficiency.During evaluation, the service facility found the probe to have poor image quality.The root cause of the poor image quality could not be determined.A history review of serial number (b)(4) showed no other similar product complaint(s) from this serial number.
Event or Problem Description
The probe was visually inspected upon receipt and was found to have poor image.

• Brand Name: REFURBISHED SITE~RITE 6 ULTRASOUND SYSTEM PROBE
• Common Device Name: SYSTEM, IMAGING, PULSED ECHO, ULTRASONIC
• MDR Report Key: 9235801
• Report Number: 3006260740-2019-03357
• Device Sequence Number: 13539124
• Product Code: IYO
• UDI-Device Identifier: 00801741125751
• UDI-Public: (01)00801741125751
• Combination Product (Y/N): N
• Initial Reporter State: WV
• Initial Reporter Country: US
• PMA/510(K) Number: K071204
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 04/27/2020

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: 9770001R
• Device Catalogue Number: 9770001R
• Device Lot Number: N/A
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 09/25/2019
• Event Location: Hospital
• Initial Date Received by Manufacturer: 10/02/2019
• Supplement Date Received by Manufacturer: 04/07/2020
• Initial Report FDA Received Date: 10/24/2019
• Supplement Report FDA Received Date: 04/27/2020
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• 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