inforMED
MalfunctionPGU

ENDOSCOPE POSITION DETECTING UNIT

Received Jun 8, 2023 · Event occurred Jan 19, 2023

Report 3002808148-2023-05751 · MDR key 17090993

Device

Generic name

Endoscope Position Detecting Unit

Model number

UPD-3

Product problems

  • Use of Incorrect Control/Treatment Settings
  • Use of Incorrect Control/Treatment Settings

Patient

Unknown

  • No Clinical Signs, Symptoms or Conditions
  • No Clinical Signs, Symptoms or Conditions

Narrative

Additional Manufacturer Narrative

THIS REPORT IS BEING SUPPLEMENTED TO PROVIDE ADDITIONAL INFORMATION BASED ADDITIONAL INFORMATION PROVIDED BY THE CUSTOMER. THE E1 "TELEPHONE NUMBER" WAS CORRECTED DUE TO INCORRECT COUNTRY CODE FORMAT. THE G2 FIELD WAS CORRECTED BASED ON THE INFORMATION AVAILABLE AT THE TIME OF THE INITIAL SUBMISSION. THE CUSTOMER CONFIRMED THERE HAVE BEEN NO REPORTS OF PATIENT USE OR HEALTH HAZARDS SINCE THE INCIDENT. THE COMPANY CONTINUES TO RECOGNIZE THAT THE USE OF THE PRODUCT IN PACEMAKER PATIENTS IS CONTRAINDICATED. THE DEVICE HISTORY RECORD WAS UNABLE TO BE REVIEWED FOR THIS DEVICE SINCE THE SERIAL NUMBER WAS NOT PROVIDED. HOWEVER, OLYMPUS ONLY RELEASES PRODUCTS TO MARKET THAT MEET ALL MANUFACTURING SPECIFICATIONS AND FINAL PRODUCT RELEASE CRITERIA.

Additional Manufacturer Narrative

THIS MDR IS BEING SUBMITTED AS PART OF A RETROSPECTIVE REVIEW AND REMEDIATION EFFORT BASED ON ENHANCEMENTS MADE TO THE COMPANY¿S MDR AND COMPLAINT HANDLING PROCESSES. CAPAS HAVE BEEN OPENED TO MANAGE THE ACTIONS THAT ARE BEING TAKEN TO REMEDIATE THIS ISSUE AND ENSURE ANY REQUIRED MDR REPORTING IS COMPLETED. THE DEVICE WAS NOT RETURNED TO OLYMPUS FOR EVALUATION. BASED ON THE RESULTS OF THE INVESTIGATION, IT IS LIKELY THAT THE EVENT WAS CAUSED BY MISUSE DUE TO MISPERCEPTION BY A PHYSICIAN. DESCRIPTIONS OF THE INDICATED PHENOMENA WERE AMBIGUOUS, AND BECAUSE NO RESPONSE FROM THE INSTITUTION WAS OBTAINED ABOUT THIS PHENOMENON, THE CAUSE AND THE INDICATED PHENOMENON WERE NOT IDENTIFIED. A DEFINITIVE ROOT CAUSE CANNOT BE IDENTIFIED. OLYMPUS WILL CONTINUE TO MONITOR THE FIELD PERFORMANCE OF THIS DEVICE.

Description of Event or Problem

THE CUSTOMER REPORTED TO OLYMPUS THAT THE DEVICE MAY HAVE BEEN USED ON A PATIENT WITH A PACEMAKER. AT THAT TIME, THE DOCTOR RECOGNIZED THAT ITS USE WAS CONTRAINDICATED. THERE WAS NO HARM OR USER INJURY REPORTED DUE TO THE EVENT.