MAUDE Adverse Event Report: JIANGSU JIANYU HEALTH MEDICAL CO LTD BLOX; ENDOSCOPIC BITE BLOCK

Model Number SBT-114-100

Device Problem Material Separation (1562)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Date 11/02/2023

Event Type  malfunction  

Manufacturer Narrative

Block h6: imdrf device code a0413 captures the reportable event of bite blox material separation.

Event Description

It was reported to boston scientific corporation that a bite blox was used during an upper gastrointestinal endoscopy performed on (b)(6) 2023.During the procedure, when the endoscope was inserted a snapping sound was heard.A broken piece was found inside the mouth and recovered.There were no oral lacerations.The procedure was completed with another bite blox.There were no patient complication as a result of this event.

Manufacturer Narrative

Block h6: imdrf device code a0413 captures the reportable event of bite blox material separation.Block h10: investigation results the returned bite blox was analyzed.Visual evaluation found that the bite blox housing was damaged.A piece of the device in the bite region was broken off, and the presence of bite marks was noted.No other problems were noted.The reported event was confirmed.Product analysis identified that the device had a broken bite piece.It is likely that a compressive bite force caused the bite blox housing to be damaged, as evidenced by the presence of bite marks.Based on all available information and analysis of the returned device, the most probable cause is adverse event related to procedure.

Event Description

It was reported to boston scientific corporation that a bite blox was used during an upper gastrointestinal endoscopy performed on (b)(6) 2023.During the procedure, when the endoscope was inserted a snapping sound was heard.A broken piece was found inside the mouth and recovered.There were no oral lacerations.The procedure was completed with another bite blox.There were no patient complication as a result of this event.

• Brand Name: BLOX
• Type of Device: ENDOSCOPIC BITE BLOCK
• Manufacturer (Section D): JIANGSU JIANYU HEALTH MEDICAL CO LTD; zhixi industry zone; jintan area; changzhou city 21325 1; CH 213251
• Manufacturer (Section G): JIANGSU JIANYU HEALTH MEDICAL CO LT; no 88 of longxi avenue; zhulin town; changzhou city 21324 1; CH 213241
• Manufacturer Contact: carole morley ; 300 boston scientific way; marlborough, MA 01752 ; 5086834015
• MDR Report Key: 18273498
• MDR Text Key: 329825764
• Report Number: 3005099803-2023-06418
• Device Sequence Number: 1
• Product Code: MNK
• Combination Product (y/n): N
• Reporter Country Code: JA
• PMA/PMN Number: EXEMPT
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Other,Foreign,Health Professional,Company Representative
• Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date: 02/07/2024

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 12/06/2023
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: SBT-114-100
• Device Catalogue Number: SBT-114-100
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 01/12/2024
• Was Device Evaluated by Manufacturer?: Yes
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1