MAUDE Adverse Event Report: HUDSON ET TUBE, SHER-I-BRONCH, LS, 41 FR; TUBE, TRACHEAL/BRONCHIAL, DIFF

Model Number	IPN048998
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	Insufficient Information (4580)
Date of Event	08/23/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).Complaint verification testing could not be performed as no sample was returned for analysis.A verification of failure mode reported in the current manufacturing process was conducted as follows on material # 5-16041 lot # 73h2100855: (b)(4) samples were taken from the current production; the samples were visually inspected, and issue reported "other" was not observed in the current manufacturing process.A device history record review was performed, and no relevant findings were identified.Without the device to evaluate the complaint could not be confirmed and the probable cause could not be determined from the available information.Teleflex will continue to monitor and trend for reports of this nature.If the sample becomes available at a later date a follow up report will be submitted with investigation results.
Event or Problem Description
It was reported "the end that has the "t" connector is literally breaking away from the rubber tube".Unknown where the issue was first observed at time of report.Unknown patient condition at time of report.

• Brand Name: HUDSON ET TUBE, SHER-I-BRONCH, LS, 41 FR
• Common Device Name: TUBE, TRACHEAL/BRONCHIAL, DIFF
• MDR Report Key: 12484985
• Report Number: 3003898360-2021-00827
• Device Sequence Number: 3936948
• Product Code: CBI
• UDI-Device Identifier: 14026704617422
• UDI-Public: 14026704617422
• Combination Product (Y/N): N
• Initial Reporter State: OR
• Initial Reporter Country: US
• PMA/510(K) Number: K180253
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,distri
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 08/23/2021

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
• Operator of Device: No Information
• Device Expiration Date: 02/15/2026
• Device Model Number: IPN048998
• Device Catalogue Number: 5-16041
• Device Lot Number: 73B2100346
• Was Device Available for Evaluation?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 08/23/2021
• Initial Report FDA Received Date: 09/16/2021
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 02/10/2021
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1