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DOI: 10.1055/s-0041-1731960
A Descriptive Analysis of Capsule Endoscopy Events in the FDA Manufacturer and User Facility Device Experience (MAUDE) Database
Abstract
Introduction The malfunction of capsule endoscopy (CE) devices is a significant reason for the failure of CE procedures, which could hinder and prevent diagnosis. Unfortunately, malfunction-related adverse events (AEs) caused by CE devices are rarely reported in publications. Although most malfunction-related AEs could not lead to physical harm, they could reduce the efficiency of medical care and increase medical costs. The manufacturer and user facility device experience (MAUDE) database, a publicly accessible resource for patient safety, contains not only the common complications of CE but also valuable malfunction-related AEs, which have been underutilized. Therefore, the study aims to discover and analyze the possible AEs associated with CE and demonstrate the utility of the MAUDE reports to promote patient safety.
Materials and Methods We acquired MAUDE reports of CE systems from January 01, 2008, to July 31, 2020, through a systematic search strategy. We utilized the manufacturers, brand names, and product codes as search terms from which medical device reports including structured data and narrative texts were extracted, followed by a manual review of the narrative texts, reporter occupation, device involved, event type and the phase of the event; finally, patient outcomes were recorded and analyzed as per CE categories and characteristics.
Results A total of 377 CEs medical device reports were retrieved, and 342 reports were included after reviewing. There were 327 mandatory reports (96%) and 15 voluntary reports (4%). These reports referred to capsule endoscope (n = 213), sensing system (n = 66), patency capsule (n = 38), and capsule delivery device (n = 26). A total of 349 CE-related AEs were identified, including complications (n = 228), malfunction-related AEs (n = 109), and other events (n = 12). The composition of AEs was not the same for the CE devices. Complications were major AEs of capsule endoscope and patency capsule, but malfunction-related AEs were the most common in AEs of sensing systems and capsule delivery devices.
Conclusion MAUDE serves as an invaluable data source for investigating malfunction-related AEs. In addition to common complications, malfunction of CE devices could threaten patient safety in CE procedures. Improving awareness of the malfunction of CE devices and raising adequate training for staff working in gastrointestinal (GI) endoscopic units could be critical and beneficial in preventing malfunction-related AEs.
Publication History
Article published online:
30 July 2021
© 2021. Society of Gastrointestinal Endoscopy of India. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).
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References
- 1 FDA. What is a Serious Adverse Event? Available at: https://www.fda.gov/safety/reporting-serious-problems-fda/what-serious-adverse-event. Accessed June 25, 2021
- 2 Patient Safety Network (PSNet). Adverse Events, Near Misses, and Errors. Available at: https://psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors. Accessed March 8, 2021
- 3 Jha AK, Larizgoitia I, Audera-Lopez C, Prasopa-Plaizier N, Waters H, Bates DW. The global burden of unsafe medical care: analytic modelling of observational studies. BMJ Qual Saf 2013; 22 (10) 809-815
- 4 World Health Organization & World Alliance for Patient Safety. Research Priority Setting Working Group. Summary of the evidence on patient safety : implications for research / Edited by Ashish Jha Available at: https://apps.who.int/iris/handle/10665/43874 Accessed May 5, 2021
- 5 Brown SL, Bright RA, Tavris DR. Medical device epidemiology and surveillance: patient safety is the bottom line. Expert Rev Med Devices 2004; 1 (01) 1-2
- 6 Matharoo M, Haycock A, Sevdalis N, Thomas-Gibson S. A prospective study of patient safety incidents in gastrointestinal endoscopy. Endosc Int Open 2017; 5 (01) E83-E89
- 7 Tremaine AM, Avram MM. FDA MAUDE data on complications with lasers, light sources, and energy-based devices. Lasers Surg Med 2015; 47 (02) 133-140
- 8 Iddan G, Meron G, Glukhovsky A, Swain P. Wireless capsule endoscopy. Nature 2000; 405 (67/85) 417
- 9 Wang A, Banerjee S, Barth BA. et al. ASGE Technology Committee. Wireless capsule endoscopy. Gastrointest Endosc 2013; 78 (06) 805-815
- 10 Hosoe N, Takabayashi K, Ogata H, Kanai T. Capsule endoscopy for small-intestinal disorders: Current status. Dig Endosc 2019; 31 (05) 498-507
- 11 Blanco-Velasco G, Palos-Cuellar R, Domínguez-García MR. et al. Utility of capsule endoscopy in the diagnosis of gastrointestinal graft-versus-host disease. Rev Gastroenterol Mex 2020;
- 12 Pai AK, Jonas MM, Fox VL. Esophageal capsule endoscopy in children and young adults with portal hypertension. J Pediatr Gastroenterol Nutr 2019; 69 (06) 641-647
- 13 Pennazio M, Spada C, Eliakim R. et al. Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2015; 47 (04) 352-376
- 14 Koulaouzidis A, Rondonotti E, Karargyris A. Small-bowel capsule endoscopy: a ten-point contemporary review. World J Gastroenterol 2013; 19 (24) 3726-3746
- 15 Ho KK, Joyce AM. Complications of capsule endoscopy. Gastrointest Endosc Clin N Am 2007; 17 (01) 169-178
- 16 Rondonotti E. Capsule retention: prevention, diagnosis and management. Ann Transl Med 2017; 5 (09) 198
- 17 Boysen M, Ritter M. Small bowel obstruction from capsule endoscopy. West J Emerg Med 2010; 11 (01) 71-73
- 18 Palmer JS, Marenah K, El F Madani, Jain K, Gupta S. Small bowel perforation following capsule endoscopy: a case report. Ann R Coll Surg Engl 2011; 93 (06) e69-e70
- 19 Yung DE, Plevris JN, Koulaouzidis A. Short article: Aspiration of capsule endoscopes: a comprehensive review of the existing literature. Eur J Gastroenterol Hepatol 2017; 29 (04) 428-434
- 20 Ensign LG, Cohen KB. A primer to the structure, content and linkage of the FDA’s Manufacturer and User Facility Device Experience (MAUDE) Files. EGEMS (Wash DC 2017; 5 (01) 12
- 21 Reason J. Human error: models and management. BMJ 2000; 320 (72/37) 768-770
- 22 Kang H, Gong Y. Creating a database for health IT events via a hybrid deep learning model. J Biomed Inform 2020; 110: 103556
- 23 Yao B, Kang H, Wang J, Zhou S, Gong Y. Exploring health information technology events from FDA MAUDE database. Studies in Health Technology and Informatics 2018; 250: 187-191
- 24 Kang H, Wang F, Zhou S, Miao Q, Gong Y. Identifying and synchronizing health information technology (HIT) events from FDA medical device reports. Stud Health Technol Inform 2017; 245: 1048-1052
- 25 Kang H, Yu Z, Gong Y. Initializing and growing a database of Health Information Technology (HIT) events by using TF-IDF and Biterm Topic Modeling. AMIA Annu Symp Proc 2018; 2017: 1024-1033
- 26 Wang E, Kang H, Gong Y. Generating a health information technology event database from FDA MAUDE reports. Studies in Health Technology and Informatics 2017; 264: 883-887
- 27 Van de Bruaene C, De Looze D, Hindryckx P. Small bowel capsule endoscopy: Where are we after almost 15 years of use?. World J Gastrointest Endosc 2015; 7 (01) 13-36
- 28 Wang J, Liang H, Kang H, Gong Y. Understanding health information technology induced medication safety events by two conceptual frameworks. Appl Clin Inform 2019; 10 (01) 158-167
- 29 Lawal OD, Mohanty M, Elder H. et al. The nature, magnitude, and reporting compliance of device-related events for intravenous patient-controlled analgesia in the FDA Manufacturer and User Facility Device Experience (MAUDE) database. Expert Opin Drug Saf 2018; 17 (04) 347-357
- 30 Friedman DCW, Lendvay TS, Hannaford B. Instrument failures for the da Vinci surgical system: a Food and Drug Administration MAUDE Database Study. Surg Endosc 2013; 27 (05) 1503-1508
- 31 Thennukonda RA, Natarajan BR. Adverse events associated with ultrasonic scalers: A manufacturer and user facility device experience database analysis. Indian J Dent Res 2015; 26 (06) 598-602
- 32 Sittig DF, Singh H. A new sociotechnical model for studying health information technology in complex adaptive healthcare systems. Qual Saf Health Care 2010; 19 (03) i68-i74
- 33 Cave D, Legnani P, de Franchis R, Lewis BS. ICCE. ICCE consensus for capsule retention. Endoscopy 2005; 37 (10) 1065-1067
- 34 Sidhu R, Sanders DS, Morris AJ, McAlindon ME. Guidelines on small bowel enteroscopy and capsule endoscopy in adults. Gut 2008; 57 (01) 125-136
- 35 Lee HS, Lim YJ, Kim KO. et al. Research Group for Capsule Endoscopy/Small Bowel Endoscopy. Outcomes and management strategies for capsule retention: a Korean Capsule Endoscopy Nationwide Database Registry Study. Dig Dis Sci 2019; 64 (11) 3240-3246
- 36 Mannami T, Ikeda G, Seno S. et al. Capsule endoscope aspiration after repeated attempts for ingesting a patency capsule. Case Rep Gastroenterol 2015; 9 (03) 347-352
- 37 Deas Jr T, Sinsel L. Ensuring patient safety and optimizing efficiency during gastrointestinal endoscopy. AORN J 2014; 99 (03) 396-406
- 38 Enns RA, Hookey L, Armstrong D. et al. Clinical practice guidelines for the use of video capsule endoscopy. Gastroenterology 2017; 152 (03) 497-514
- 39 Rondonotti E, Herrerias JM, Pennazio M, Caunedo A, Mascarenhas-Saraiva M, de Franchis R. Complications, limitations, and failures of capsule endoscopy: a review of 733 cases. Gastrointest Endosc 2005; 62 (05) 712-716
- 40 Hebballi NB, Ramoni R, Kalenderian E. et al. The dangers of dental devices as reported in the food and drug administration manufacturer and user facility device experience database. J Am Dent Assoc 2015; 146 (02) 102-110
- 41 Leighton JA, Srivathsan K, Carey EJ. et al. Safety of wireless capsule endoscopy in patients with implantable cardiac defibrillators. Am J Gastroenterol 2005; 100 (08) 1728-1731
- 42 Bandorski D, Höltgen R, Stunder D, Keuchel M. Capsule endoscopy in patients with cardiac pacemakers, implantable cardioverter defibrillators and left heart assist devices. Ann Gastroenterol 2014; 27 (01) 3-8
- 43 Gurtcheff SE. Introduction to the MAUDE database. Clin Obstet Gynecol 2008; 51 (01) 120-123