SPYGLASS DIRECT VISUALIZATION SYSTEM M00546230 4623

MAUDE Adverse Event Report

MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a 05,07 report with the FDA on 2012-03-19 for SPYGLASS DIRECT VISUALIZATION SYSTEM M00546230 4623 manufactured by Boston Scientific - Marlborough.

Event Text Entries

[2409319] It was reported to boston scientific corporation that a spyscope access and delivery catheter was used during an ercp (endoscopic retrograde cholangiopancreatography) procedure on (b)(6), 2012. According to the complainant, during the ercp procedure the physician reported that a small yellow tubular piece of plastic was found in the patient. Prior to the fragment being found, a rx extraction balloon and olympus scope had been used with no reported malfunctions. The physician claims that the fragment had detached from the spyscope, however could not report any visible damage to the device. The fragment was unable to be recovered and was passed in the patient's stool. The procedure was completed with the same spyscope with no patient complications. There were no issues or harm to the patient reported.
Patient Sequence No: 1, Text Type: D, B5


[9696444] (b)(4):the complainant was unable to provide the suspect device lot number; therefore, the lot expiration and device manufacture dates are unknown. The complainant indicated that the device was disposed and will not be returned for evaluation; therefore a failure analysis of the complaint device could not be completed. If any further relevant information is identified, a supplemental medwatch will be filed.
Patient Sequence No: 1, Text Type: N, H10


MAUDE Entry Details

Report Number3005099803-2012-01036
MDR Report Key2495678
Report Source05,07
Date Received2012-03-19
Date of Report2012-02-27
Date of Event2012-02-24
Date Mfgr Received2012-02-27
Date Added to Maude2012-03-19
Event Key0
Report Source CodeManufacturer report
Manufacturer LinkY
Number of Patients in Event0
Adverse Event Flag3
Product Problem Flag3
Reprocessed and Reused Flag3
Health Professional3
Initial Report to FDA3
Report to FDA0
Event Location0
Manufacturer ContactEMP. CHARLES MONTGOMERY
Manufacturer Street100 BOSTON SCIENTIFIC WAY
Manufacturer CityMARLBOROUGH MA 01752
Manufacturer CountryUS
Manufacturer Postal01752
Manufacturer Phone5086834000
Manufacturer G1MEDVENTURE TECHNOLOGY CORPORATION
Manufacturer Street2301 CENTENNIAL BOULEVARD
Manufacturer CityJEFFERSONVILLE IN 47130
Manufacturer CountryUS
Manufacturer Postal Code47130
Single Use3
Previous Use Code3
Event Type3
Type of Report3

Device Details

Brand NameSPYGLASS DIRECT VISUALIZATION SYSTEM
Generic NameMINI ENDOSCOPE, GASTROENTEROLOGY-UROLOGY
Product CodeODF
Date Received2012-03-19
Model NumberM00546230
Catalog Number4623
OperatorPHYSICIAN
Device AvailabilityN
Device Eval'ed by MfgrR
Device Sequence No1
Device Event Key0
ManufacturerBOSTON SCIENTIFIC - MARLBOROUGH
Manufacturer Address100 BOSTON SCIENTIFIC WAY MARLBOROUGH MA 01752 US 01752


Patients

Patient NumberTreatmentOutcomeDate
101. Required No Informationntervention 2012-03-19

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