MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION FUSE; ENDOSCOPE, ACCESSORIES, IMAGE POST-PROCESSING FOR COLOR ENHANCEMENT

Model Number	FSC330-G7529
Medical Device Problem Code	Image Display Error/Artifact (1304)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	10/09/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).A fuse scope was received for analysis.A visual analysis was performed and found an internal wiring failure of the charge-coupled device (ccd) circuit at the distal tip.The ccd was replaced to resolve the issue.The reported issue was confirmed when the scope was angulated at the distal tip.Based on a thorough review of the reported complaint, the most probable cause for this complaint is cause traced to component failure.This complaint investigation conclusion code was utilized for an expected or random component failure without any design or manufacturing issue.Based on the results of this investigation, no escalation is necessary.The repair history was reviewed and nothing was found to indicate a possible service-related cause for the complaint.
Event or Problem Description
It was reported to boston scientific corporation that a fuse c38s slim colonoscope - s was used during a colonoscopy procedure performed on (b)(6) 2019.According to the complainant, during the procedure, the images turned black when the scope was angulated.The anatomy of the patient was not visible on center image when the issue occurred.Another fuse c38s slim colonoscope - s was used to complete the procedure.There were no patient complications reported as a result of this event.

• Brand Name: FUSE
• Common Device Name: ENDOSCOPE, ACCESSORIES, IMAGE POST-PROCESSING FOR COLOR ENHANCEMENT
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; 300 boston scientific way; marlborough MA 01752
• MDR Report Key: 9272141
• Report Number: 3005099803-2019-05289
• Device Sequence Number: 10795394
• Product Code: PEA
• UDI-Device Identifier: 00840253109583
• UDI-Public: 00840253109583
• Combination Product (Y/N): N
• Initial Reporter State: NC
• Initial Reporter Country: US
• PMA/510(K) Number: K160275
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 11/04/2019

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: FSC330-G7529
• Device Catalogue Number: 60093
• Device Lot Number: 0002600224
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 10/10/2019
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 10/09/2019
• Initial Report FDA Received Date: 11/04/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1