MAUDE Adverse Event Report: CONVATEC INC L3O0675 - ESTEEM+; I

Model Number	421626
Medical Device Problem Code	Sharp Edges (4013)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Device 6 of 7.Common device name: pouch, colostomy.Contact office address: (b)(6).Based on the available information, this event is deemed to be a reportable malfunction.To date no additional information has been received.Should additional information become available, a follow-up report will be submitted.Fda registration number reporting site: (b)(4).Third party manufacturing site (for life): (b)(4).
Event or Problem Description
The end user's wife reported that the edge of the opening was rough instead of smooth in 7 out of 10 appliances.The product was not used on patient.Photograph depicting the issue was received from the complainant.
Additional Manufacturer Narrative
C22 and d17 were selected under imdrf investigation findings and imdrf cause conclusions respectively since there is no code to describe the term "allowed deviation/tolerances for cutting guides".A batch record review indicates no discrepancies.A slightly offset hole can have the following cause: the cutting guides are not 100% evenly positioned on the carrier , according to raw material is -+ 1 mm deviation is allowed & in our technical drawings are also cutting specifications of the wafer+- 1 mm allowed, if both the position of the cutting guide on the carrier and cutting process on the machine move within allowed tolerances by +-1 mm, this could result in a total of +-2 mm deviation.Registration of the complaint and the analysis of the case: we classify the complaint as uncritical, we do not have any picture regard it the complaint, so we can only assume that if wafer stoma opening was off-centered approximately 2 mm, the maximal cutting option will be guaranteed and the function of the bag will also be guaranteed.Corrective action(s) - no corrective action required, the defect on the bag can not be corrected because is disposable product and besides does not need the correction because in all large the cuttability is guaranteed.Sensitization of the employees if the hole on the patch does not move approved tolerance range to sort out the bags/patches.Supplier investigation report attached to child investigation record.The investigation associated with related event record has been approved and was complete.No additional action is required, and this complaint will be closed.This issue will be monitored through the post market product monitoring review process.To date no additional information has been received.Should additional information become available, a follow-up report will be submitted.Fda registration number: reporting site: 1049092.Third party manufacturing site (for life): 3003759552.
Event or Problem Description
To date no additional patient or event details have been received.

• Brand Name: L3O0675 - ESTEEM+
• Common Device Name: I
• Manufacturer (Section D): CONVATEC INC; 211 american avenue; greensboro NC
• Manufacturer (Section G): CONVATEC INC; 211 american avenue; greensboro NC
• Manufacturer Contact: pamela meadows ; 7815 national service road; suite 600; greensboro, NC ; 3365424679
• MDR Report Key: 12365044
• Report Number: 1049092-2021-00089
• Device Sequence Number: 4418836
• Product Code: EZQ
• UDI-Device Identifier: 00768455197552
• UDI-Public: 00768455197552
• Combination Product (Y/N): N
• Initial Reporter State: OK
• PMA/510(K) Number: EXEMPT
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Other
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 07/30/2021

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
• Device Expiration Date: 02/01/2023
• Device Model Number: 421626
• Device Lot Number: 0000252523
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 07/30/2021
• Supplement Date Received by Manufacturer: 08/01/2023
• Initial Report FDA Received Date: 08/25/2021
• Supplement Report FDA Received Date: 08/25/2023
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 02/28/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Unknown
• Patient Sequence Number: 1
• Patient Sex: Unknown