MAUDE Adverse Event Report: CARDINAL HEALTH BALLOON SLG 14FR X 2.0CM; TUBES, GASTROINTESTINAL (AND ACCESSORIES)

Model Number	714200
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	09/01/2021
Type of Reportable Event	Malfunction
Event or Problem Description
The customer reported that the shaft is broken where it meets the top of the tube causing profuse leakage.
Additional Manufacturer Narrative
An investigation is currently underway.Upon completion, the results will be forwarded.
Additional Manufacturer Narrative
No samples or photos were received for the investigation.The device history record (dhr) was reviewed, and no abnormal process conditions were present during the manufacturing of the product that could have led to the reported condition.The dhr review showed that all acceptance criteria inspections per established sampling levels were within acceptable limits during the production process.Based on the present information, and since no photos or a physical sample was received, the reported issue could not be confirmed.All associated lot documentation was carefully reviewed; no issues or discrepancies were found relating to the reported complaint.No non-conformities nor deviations were reported for this lot for this issue.A corrective action is not applicable at this time.Current process controls are executed in accordance with product specifications to meet quality acceptance criteria.The manufacturing site will continue to monitor the process, customer complaints and feedback notifications for any adverse trends that require immediate attention.If a sample is received at a later date, the investigation will be updated accordingly.

• Brand Name: BALLOON SLG 14FR X 2.0CM
• Common Device Name: TUBES, GASTROINTESTINAL (AND ACCESSORIES)
• Manufacturer (Section D): CARDINAL HEALTH; calle 9 sur no. 125 cuidad ind; tijuana 22500 ; MX 22500
• Manufacturer (Section G): CARDINAL HEALTH; calle 9 sur no. 125 cuidad ind; tijuana 22500 ; MX 22500
• Manufacturer Contact: jill saraiva ; 777 west street; mansfield, MA 02048 ; 5086183640
• MDR Report Key: 13445364
• Report Number: 9612030-2022-03152
• Device Sequence Number: 2161094
• Product Code: KNT
• UDI-Device Identifier: 10884521010666
• UDI-Public: 10884521010666
• Combination Product (Y/N): N
• Initial Reporter Country: AS
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,User Facility,Company Representative
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 03/09/2022

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 Model Number: 714200
• Device Catalogue Number: 714200
• Device Lot Number: 1833814864
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 01/20/2022
• Supplement Date Received by Manufacturer: 01/20/2022
• Initial Report FDA Received Date: 02/03/2022
• Supplement Report FDA Received Date: 03/09/2022
• Is the Device Labeled for Single Use? (Y/N): Yes
• Usage of Device: A
• Patient Sequence Number: 1
• Patient Sex: Unknown