MAUDE Adverse Event Report: AVANOS MEDICAL INC. UNKNOWN PEG JEJUNOSTOMY TUBE; DH EF BALLOON TUBES PRODUCTS

Model Number UNKNOWN

Device Problem Migration or Expulsion of Device (1395)

Patient Problem Skin Infection (4544)

Event Date 06/17/2021

Event Type  Injury  

Manufacturer Narrative

The actual complaint product was not returned for evaluation.Root cause could not be determined.A review of the device history record is not possible as no lot number was provided.All information reasonably known as of (b)(6) 2021 has been included in this health authority report.Should additional information be obtained, a follow-up health authority report will be provided.The information provided by avanos medical inc.Represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to avanos medical inc.Avanos medical inc.Has no independent knowledge of the event reported but is relaying the information that was provided by the user facility where the incident occurred.This product incident is documented in the avanos medical complaint database and identified as complaint (b)(4).This information is submitted pursuant to 21cfr803, in compliance with the medical device reporting requirement and should not be considered to be an admission that an avanos medical inc.Product is defective or caused serious injury.

Event Description

It was reported by the patient to the distributor that on (b)(6) 2021 the patient's peg jejunstomy tube had migrated four inches out, and in addition, the patient had been experiencing a stoma site infection for three days and has been on antibiotics.The patient reported that there was now pus coming from the stoma site, but it was not bleeding or painful.The patient reported that they had discontinued use of the duodopa pump, but had oral medication (carbidopa/levodopa) to take instead.The patient had determined that he will go to the emergency room to be seen regarding the stoma site infection.Per additional information received 23 jun 2021, the patient was taking cefadroxil antibiotic for the stoma infection starting on (b)(6) 2021.When the patient was seen at the er on (b)(6) 2021, he was prescribed a stronger oral antibiotic, sulfameth/trimethoprim, for the infection, and continues to take at this time.Per additional information provided by the distributor on 28 jun 2021, the patient stated they went to (b)(6) hospital and medical center at (b)(6).

• Brand Name: UNKNOWN PEG JEJUNOSTOMY TUBE
• Type of Device: DH EF BALLOON TUBES PRODUCTS
• Manufacturer (Section D): AVANOS MEDICAL INC.; 5405 windward parkway; alpharetta GA 30004
• Manufacturer (Section G): AVENT SA DE R.L. DE C.V. (AVENT 1); circuito industial no.40; colonia obrera; nogales, cp 84048 ; MX 84048
• Manufacturer Contact: lisa clark ; 5405 windward parkway; alpharetta, GA 30004 ; 4704485444
• MDR Report Key: 12168314
• MDR Text Key: 269607452
• Report Number: 9611594-2021-00096
• Device Sequence Number: 1
• Product Code: KNT
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: UNKNOWN
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: consumer,distributor
• Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date: 07/14/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 07/14/2021
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Device Operator: Lay User/Patient
• Device Model Number: UNKNOWN
• Device Catalogue Number: N/A
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Date Manufacturer Received: 06/22/2021
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Unknown
• Patient Sequence Number: 1
• Patient Outcome(s): Required Intervention
• Patient Age: 76 YR