MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a company representative,distri report with the FDA on 2018-03-26 for WORKING INSERT, ALBARRAN, TWO WAY A20972A manufactured by Olympus Winter & Ibe Gmbh.
[103810227]
The suspect medical device has not yet been returned to olympus for evaluation/investigation. Therefore, the exact cause of the user's experience and the reported phenomenon could not be determined and is being judged as unknown. However, if the suspect medical device is returned for evaluation/investigation or additional significant information becomes available, this report will be updated.
Patient Sequence No: 1, Text Type: N, H10
[103810228]
Olympus was informed that during inspection prior to an unspecified cystoscopy procedure, it was noticed that the albarran lever at the distal end of the working insert could not be raised and that its fixing pin was missing. It is unknown when this damage occurred and whether the fixing pin possibly fell off inside the patient during a previous procedure. Since this damage was detected prior to use, the intended cystoscopy procedure was canceled. There was no report about an adverse event or patient injury.
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 9610773-2018-00027 |
| MDR Report Key | 7369009 |
| Report Source | COMPANY REPRESENTATIVE,DISTRI |
| Date Received | 2018-03-26 |
| Date of Report | 2018-04-04 |
| Date of Event | 2018-03-01 |
| Date Mfgr Received | 2018-03-30 |
| Device Manufacturer Date | 2005-01-25 |
| Date Added to Maude | 2018-03-26 |
| Event Key | 0 |
| Report Source Code | Manufacturer report |
| Manufacturer Link | Y |
| Number of Patients in Event | 0 |
| Adverse Event Flag | 3 |
| Product Problem Flag | 3 |
| Reprocessed and Reused Flag | 3 |
| Health Professional | 3 |
| Initial Report to FDA | 3 |
| Report to FDA | 3 |
| Event Location | 3 |
| Manufacturer Contact | MR. DANIEL WLADOW |
| Manufacturer Street | KUEHNSTRASSE 61 |
| Manufacturer City | HAMBURG |
| Manufacturer Country | US |
| Manufacturer Phone | 4940669662 |
| Manufacturer G1 | OLYMPUS WINTER & IBE GMBH |
| Manufacturer Street | KUEHNSTRASSE 61 |
| Manufacturer City | HAMBURG |
| Manufacturer Country | US |
| Single Use | 3 |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | WORKING INSERT, ALBARRAN, TWO WAY |
| Generic Name | WORKING INSERTS WITH ALBARAN LEVER |
| Product Code | GCP |
| Date Received | 2018-03-26 |
| Model Number | A20972A |
| Catalog Number | A20972A |
| Lot Number | 051W |
| ID Number | 04042761020374 |
| Operator | HEALTH PROFESSIONAL |
| Device Availability | Y |
| Device Age | DA |
| Device Eval'ed by Mfgr | R |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | OLYMPUS WINTER & IBE GMBH |
| Manufacturer Address | KUEHNSTRASSE 61 HAMBURG US |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 2018-03-26 |