inforMED
MalfunctionILY

THOR PHOTOMEDICINE LTD

Received Apr 3, 2025 · Event occurred Mar 6, 2025

Report 3003899624-2025-00005 · MDR key 21761353

Device

Generic name

S1160 810nm 1w Cluster (5x200mw) Issue 2

Model number

S1160

Product problems

  • Excessive Heating
  • Excessive Heating

Patient

NA · Unknown

  • Erythema
  • Skin Burning Sensation
  • Erythema
  • Skin Burning Sensation

Narrative

Description of Event or Problem

PATIENTS COMPLAINING OF FEELING LIKE THEY ARE GETTING BURNED AND STAFF SAYS HANDPIECES FEEL HOT. ONE PATIENT ACTUALLY HAD A SMALL BURN MARK. CURRENTLY, TWO OF OUR FOUR LASER HEADS HAVE OVERHEATED, CAUSING PATIENT DISCOMFORT AND LEAVING REDNESS ON THEIR SKIN.

Additional Manufacturer Narrative

THIS REPORT IS RELATED TO THE REPORTS 3003899624-2025-00004 AND 3003899624-2025-00006. THE ISSUES ARE REPORTED FROM THE SAME HEALTH CARE FACILITY FOR ONE THERAPY SYSTEM THAT CONTAINS THREE TREATMENT PROBES THAT WERE ALLEGEDLY FOUND TO BE OVERHEATING. IN THE CLINICIANS' OWN WORDS: "PATIENTS COMPLAINING OF FEELING LIKE THEY ARE GETTING BURNED AND STAFF SAYS HANDPIECES FEEL HOT. ONE PATIENT ACTUALLY HAD A SMALL BURN MARK. LOWER RIGHT HANDPIECE CONNECTOR THREADS ARE STRIPPED. DUE TO THE NATURE OF OUR PATIENT POPULATION, WHICH INCLUDES INDIVIDUALS WITH CANCER-RELATED SYMPTOMS, PAIN SYNDROMES, AND TENDONITIS, OUR UNIT IS USED EXTENSIVELY THROUGHOUT A TWELVE-HOUR DAY BY SEVERAL THERAPISTS. THIS IS OUR ONLY UNIT, AND FOR SOME OF OUR PATIENTS, IT IS THE PRIMARY TREATMENT THEY RELY ON. UNFORTUNATELY, WE HAVE HAD TO PLACE TREATMENTS ON HOLD FOR NOW. CURRENTLY, TWO OF OUR LASER HEADS HAVE OVERHEATED, CAUSING PATIENT DISCOMFORT, AND LEAVING REDNESS ON THEIR SKIN". THE PRACTITIONER REPORTED THAT ALL THE RED MARKS HAD BEEN MILD, TRANSIENT AND HAD RESOLVED. THE S1160 810 NM 1W CLUSTER (5 X 200 MW) ISSUE 2 TREATMENT PROBE (SERIAL NUMBER (B)(6)) WAS RETURNED TO THOR AND UNDERWENT TEMPERATURE TESTING. IT WAS IDENTIFIED THAT THE TEMPERATURE RISES ABOVE THE SPECIFIED LIMIT OF 41 DEGREES C DURING 10 MINUTES OF CONTINUOUS USE. THE ISSUE WAS TRACED TO WEAR AND TEAR OF THE PROBE CABLE AND RESISTOR.

Remedial action

  • Repair