MAUDE MDR 1378311

MDR report key
1378311
Report number
3003508375-2009-00002
Event key
0
Event type
3
Date of event
2009-04-22
Date received
2009-05-06
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
0
Health professional
3
Initial report to FDA
3
Event location
0

Manufacturer Contact#

Contact
MICHAEL O'MEARA, DIR
Address
ROUTE 22 WEST SOMERVILLE NJ 08876 US
Phone
908-908-9087
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1INDEPENDENCE IBOT 4000 MOBILITY SYSTEMSTAIR CLIMBING WHEELCHAIRINDEPENDENCE TECHNOLOGY, LLCIMKNAIT004021NAY N

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12009-05-0601. O

Event Narratives#

D

Patient 1

USER REPORTED A FALL DOWN A SET OF FIVE STEPS IN STANDARD FUNCTION WITH THE DEVICE, AND THAT SHE FELL FROM THE DEVICE AT THE BOTTOM OF THE STEPS. USER STATED THAT SHE HAD NOT INTENDED TO DESCEND THE STEPS, AND THAT THE DEVICE STARTED ROLLING ON ITS OWN. USER INITIALLY REPORTED INJURIES CONSISTING OF BUMPS, ABRASIONS AND CONTUSIONS TO HER RIGHT KNEE, RIGHT SHOULDER, AND A SWOLLEN/BRUISED LEFT WRIST. WHEN ASKED IF SHE WAS CERTAIN THAT THE DEVICE MADE AN UNCOMMANDED MOVE, USER REPLIED THAT SHE "PRETTY SURE", BUT THAT SHE WAS WALKING HER DOG ON A LEASH AT THE TIME AND THAT IT WAS "POSSIBLE THE DOGS LEASH HIT THE JOYSTICK, AND CAUSED THE DEVICE TO MOVE BUT SHE DOESN'T THINK SO". USER WAS NOT WEARING THE PROVIDED LAP BELT AT THE TIME OF THE EVENT. VIA AN ONLINE POSTING BY THE USER, THE COMPANY BECAME AWARE THAT THE USER HAD ALSO SUSTAINED AN UNREPORTED IMPACT TO THE BACK OF THE HEAD, ALONG WITH NECK PAIN, AND SUBSEQUENTLY SOUGHT MEDICAL ATTENTION, THE RESULTS OF WHICH WERE NEGATIVE. (B)(4).

N

Patient 1

SERVICE WAS DISPATCHED TO RETRIEVE THE ELECTRONIC CONFIGURATION FILE (ECF) AND INSPECT THE DEVICE FOLLOWING THE EVENT. A REPORT ON FIELD SERVICE ACTIVITY (SAR) AND A DEVICE CHECKOUT RECORD (FCR) WAS FORWARDED TO THE COMPLAINT HANDLING UNIT (CHU) PER STANDARD OPERATING PROCEDURE. THE USER HAS NOT REPORTED ANY RECURRENCE OF THE EVENT SINCE THE COMPLETION OF THE SERVICE ACTIVITY. THE ECF ANALYSIS INDICATED THAT THE DEVICE HAD NO ALARMS, NO SERVICE WRENCH, AND NO BLACK BOX DATA. THIS IS NORMAL FOR STANDARD FUNCTION. INDICATIONS ARE THAT THE DEVICE WAS DRIVEN DOWN THE STAIRS IN STANDARD FUNCTION. THE USER INDICATED THAT THE WHEEL CASTERS WERE STUCK ON A THRESHOLD WHEN SHE WAS EXITING A DOOR, AND THAT SHE PUSHED HARD ON THE JOYSTICK TO DRIVE OVER THE THRESHOLD. ONCE THE CASTERS OVERCAME THE OBSTACLE, THE DEVICE DROVE QUICKLY FORWARD AND FELL DOWN THE STAIRS. ENGINEERING ANALYSIS SUGGESTS THAT THIS SCENARIO IS PLAUSIBLE, AS THE USER CREATED AN INCREASED TORQUE WHEN PUSHING THE JOYSTICK FORWARD WITH THE WHEELS STUCK. BASED ON KNOWN INFORMATION ABOUT THE EVENT, THERE IS NO EVIDENCE OF A DEVICE MALFUNCTION. AS OF 05/06/2009, THE COMPANY HAS UNSUCCESSFULLY ATTEMPTED TO CONTACT THE USER TO REVIEW FINDINGS AND FEEDBACK ON THE CIRCUMSTANCES OF THE EVENT, AND PROVIDE GUIDANCE ON HOW TO AVOID RECURRENCE WHEN EXITING THE SUBJECT DOORWAY.