MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION ULTRA ICE PLUS; TRANSDUCER, ULTRASONIC, DIAGNOSTIC

Model Number	M00499120
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	04/09/2020
Type of Reportable Event	Malfunction
Event or Problem Description
Incident description: catheter was inserted into patient, was not working properly.Removed and a crack in catheter lining was noted.Subsequently, another boston scientific 8.5f 110cm cath ultra ice plus echo was used.The procedure was completed without complications.

• Brand Name: ULTRA ICE PLUS
• Common Device Name: TRANSDUCER, ULTRASONIC, DIAGNOSTIC
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; 300 boston scientific way; marlborough MA 01752
• MDR Report Key: 10095874
• Report Number: 10095874
• Device Sequence Number: 3386835
• Product Code: ITX
• UDI-Device Identifier: 08714729904380
• UDI-Public: (01)08714729904380(17)211205(10)24887480
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: User Facility
• Initial Reporter Occupation: Nurse
• Type of Report: Initial
• Report Date (Section B): 05/21/2020
• Report Date (Section F): 05/21/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Model Number: M00499120
• Device Lot Number: 24887480
• Was Device Available for Evaluation?: Yes
• Was the Report Sent to FDA?: Yes
• Event Location: Hospital
• Date Report to Manufacturer: 05/28/2020
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 05/28/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Weight: 100
• Date Report Sent to FDA: 05/21/2020