Template: Incident Assessment Form

Regulatory References:

Regulation / Standard Description
EU Regulation 2017/745 (MDR) Articles 87 and 89 (Incident analysis, vigilance, field safety corrective actions)
ISO 13485:2016 Section 8.2.3
German Medical Devices Law (MPDG) Chapter 5, Articles 71–83
German Medical Device EU Adjustment Ordinance (MPEUAnpV) All
MDCG 2023-3 All
MEDDEV 2.12/1 rev. 8 All

Related Documents:
– SOP Vigilance


Purpose

This form evaluates whether an event with potential adverse effects on health constitutes a serious, reportable incident.


Incident Overview

Field Details
Event Description \
Report Date & Time
Affected Device \
Incident Classification ( ) Reportable Incident ( ) Non-Reportable Incident
Proposed Action \

Incident Assessment Criteria

Based on guidance from MEDDEV 2.12/1 rev. 8 and MDCG 2023-03, events that satisfy all three criteria below qualify as serious incidents and must be reported. Non-reportable incidents should still be documented and reviewed as part of quality processes like CAPA or post-market surveillance.

Note: This form can also be used to justify why an event is not deemed a reportable incident.

Criterion 1: Event Description

Definition: An event has occurred that aligns with the definition of an incident under Article 2(64) MDR.

An “incident” refers to any malfunction, performance deterioration, use-error (due to ergonomic issues), insufficient information provided by the manufacturer, or undesirable side-effect.

Field Response
Applicable? ( ) Yes ( ) No
Explanation: \
Event Category:

Examples of incidents:
– Technical failures resulting in device malfunctions.
– Unclear or insufficient instructions for use.
– Ergonomic issues causing user errors.
– Undesirable side effects (refer to MDCG 2023-3, para. 8).


Criterion 2: Device-Event Relationship

Definition: A causal relationship between the device and the event is confirmed, reasonably likely, or suspected.

Field Response
Applicable? ( ) Yes ( ) No
Explanation: \

Considerations:
– Expert opinions (e.g., physicians).
– Prior incidents with similar characteristics.
– PRRC (Person Responsible for Regulatory Compliance) assessment.


Criterion 3: Event Outcomes

Definition: The event caused, might cause, or could potentially cause:

Outcome Applicable?
Death of a patient, user, or another person ( ) Yes ( ) No
Serious deterioration in health ( ) Yes ( ) No
Serious public health threat ( ) Yes ( ) No

Serious deterioration in health includes:
– Life-threatening illness or injury.
– Permanent impairment of body structure or function.
– Prolonged hospitalization.
– Need for medical or surgical intervention.
– Chronic disease.
– Indirect harm due to diagnostic errors.

Field Response
Applicable? ( ) Yes ( ) No
Explanation: \

Key References for Decision-Making

Reference Explanation
Intended Use Defined use according to the manufacturer’s labeling, instructions, or promotional material (MEDDEV 2.12/1, Section 4.6).
Incident Definition Malfunctions, performance deterioration, or inadequate labeling/instructions that could lead to death or health risks (MEDDEV 2.12/1, Annex I).
Direct/Indirect Harm Harm resulting directly or indirectly from the device, including delayed treatment or incorrect diagnostic results.
FSCA (Field Safety Corrective Actions) Manufacturer actions to address risks associated with device use, including modifications, recalls, or updates (MEDDEV 2.12/1).

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