MAUDE MDR 6652000

MDR report key
6652000
Report number
0002936921-2017-00010
Event key
0
Event type
3
Date of event
2017-05-24
Date received
2017-06-19
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
1
Health professional
3
Initial report to FDA
3
Event location
3

Manufacturer Contact#

Contact
MR. TOSHIO MURATA
Address
47651 WESTINGHOUSE DRIVE FREMONT CA 94539 US
Phone
800-800-8002
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1RT-5100REFRACTORNIDEK CO., LTD.HKNN Y

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12017-06-190

Event Narratives#

N

Patient 1

NO SERIOUS INJURY OCCURRED AND NO KNOWN IMPACT OR CONSEQUENCE TO THE DOCTOR INVOLVED. HOWEVER, NIDEK INCORPORATED CONSIDERS THIS ISSUE A REPORTABLE EVENT AS THE DEVICE HAD MALFUNCTIONED AND HAS A POTENTIAL TO CAUSE OR CONTRIBUTE TO A SERIOUS INJURY IF THE MALFUNCTION WERE TO RECUR. NIDEK HIRED THIRD PARTY (B)(4) TO PERFORM THE CORRECTION AS PER RECALL (Z-1245-2016). AT THIS TIME, DEVICE EVALUATION ANTICIPATED BUT HAS NOT BEGUN. THEREFORE, A FOLLOW-UP WILL BE SUBMITTED ONCE THE EVALUATION IS COMPLETED.

D

Patient 1

ON MAY 24, 2017, DURING RECALL PROCESS, A NIDEK INCORPORATED RECALL COORDINATOR RECEIVED INFORMATION FROM A CUSTOMER THAT THE NEAR POINT CHART ROD ON THEIR RT-5100 SERIAL #(B)(4) FALLS AND HAD HIT HER AND TWO DOCTORS IN THE HEAD ON MULTIPLE OCCASIONS WHILE CLEANING OR SETTING UP. THE TECHNICIAN CLAIMED THAT IT WAS NOT A BIG DEAL, OTHER THAN THE INCONVENIENCE AND FURTHERMORE STATED THAT NO SERIOUS INJURIES OCCURRED FROM THE INCIDENT, THEREBY, MEDICAL TREATMENT/INTERVENTION WAS UNNECESSARY.