Alerta De Seguridad para ANGIX MOD. ADV. ANVISA registration: 80260940001.

Según Agência Nacional de Vigilância Sanitária (ANVISA), este evento ( alerta de seguridad ) involucró a un dispositivo médico en Brazil que fue producido por XPRO Sistemas Ltda..

¿Qué es esto?

Las alertas proporcionan información importante y recomendaciones sobre los productos. Aunque se haya emitido una alerta, esto no significa necesariamente que el producto se considera peligroso. Las alertas de seguridad, dirigidas a trabajadores de la salud y a usuarios, pueden incluir retiro de equipos. Pueden ser escritas por los fabricantes, pero también por funcionarios del área de salud.

Más información acerca de la data acá
  • Tipo de evento
    Safety alert
  • ID del evento
    1436
  • Fecha
    2014-10-17
  • País del evento
  • Fuente del evento
    ANVISA
  • URL de la fuente del evento
  • Notas / Alertas
    Brazilian data is current through June 2018. All of the data comes from Anvisa, except for the categories Manufacturer Parent Company and Product Classification.
    The Parent Company and the Product Classification were added by ICIJ.
    The parent company information is based on 2017 public records. The device classification information comes from FDA’s Product Classification by Review Panel, based on matches of data from the U.S. and Brazil.
  • Notas adicionales en la data
    There is a report of a product-related adverse event: during a procedure, the operator, while making a bow movement, collided the x-ray tube against the bottom of the table, thereby triggering the anti-collision sensor. The image detector, then instead of moving away from the patient, made the opposite movement as expected and moved downward, pressing the patient's arm against the table causing a slight hematoma without further damage. The unexpected movement was quickly noticed by the operator, and the emergency button was triggered by de-energizing the equipment immediately. The event occurred due to a firmware failure (software embedded in an integrated circuit), occurring only when there is an event sequence. There is already a new version with a bug fix. A risk analysis was performed, and the severity of the risk was classified as severe, as there may be possibility of dislocations and fractures. The probability of occurrence (P1) was classified as Remote because there is a combination of factors necessary for the unexpected movement of the detector to occur. In the history of complaints, there was only this single event of involuntary movement of the detector, according to records of the last 365 days. The probability of damage (P2) was classified as improbable because the operator has the entire visual field of the equipment and can interrupt the event immediately when observed. For example, the operator can turn off the system via the emergency button on the console. In addition to this feature, another existing mitigation is that the movement of the detector shaft is limited to 10 mm when the emergency button is actuated. However, because a situation classified as RMR was detected (RMR - necessary risk mitigation), this field action was required due to this adverse post-marketing event.
  • Causa
    Incorrect movement of the equipment, activated by the anti-collision sensor.
  • Acción
    Software update scheduled to be finalized by December 2014. To prevent non-intentional motion of the image intensifier, follow the instructions below: 1. When unintentional movement is observed, immediately press the emergency button located on the user interface on the side of the table; 2. Ensure that all operators are trained and aware of the safety procedures for the ANGIX systems and that the system is locked properly when transferring a patient; 3. When operating your system care must be taken when operating the image intensifier and x-ray tube to avoid collisions.

Manufacturer

  • Source
    ANVSANVISA