MAUDE Adverse Event Report: SMITHS MEDICAL ASD, INC. FOME-CUF-WIRE RE-ENFORCED, AIRE-CUF WIRE; TUBE, TRACHEAL (W/WO CONNECTOR)

Model Number	35W080
Medical Device Problem Codes	Delivered as Unsterile Product (1421); Unsealed Device Packaging (1444)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
A device history record (dhr) review was conducted which indicated all inspections were completed and no issues were noted during manufacture.A product sample was received for evaluation.Visual and functional testing were performed.Two (2) product samples were received for evaluation.Visual inspection of the pouch seal did reveal openings.The pouch was cut open at the vendor's seal and positioned on the burst tester.Under functional testing of the seal, the seal did exceed the minimum burst test.The root cause of the reported issue could not be confirmed.The investigation does not identify a manufacturing issue with the returned samples.An internal non-conformance report (ncr) has been opened to address the multiple complaints received by a single complainant.This remediation mdr was generated under protocol b10009406, as a result of warning letter cms# (b)(4).
Event or Problem Description
It was reported that the sterility of the device was compromised, as the bottom of the package was not sealed completely and the tube sticks out of the end.No patient injury was reported.

• Brand Name: FOME-CUF-WIRE RE-ENFORCED, AIRE-CUF WIRE
• Common Device Name: TUBE, TRACHEAL (W/WO CONNECTOR)
• Manufacturer (Section D): SMITHS MEDICAL ASD, INC.; 5700 west 23rd ave; gary IN 46406
• Manufacturer (Section G): SMITHS MEDICAL ASD, INC.; 5700 west 23rd ave; gary IN 46406
• Manufacturer Contact: jim vegel ; 6000 nathan lane north; minneapolis, MN 55442
• MDR Report Key: 15353693
• Report Number: 3012307300-2022-17591
• Device Sequence Number: 12310208
• Product Code: BTR
• UDI-Device Identifier: 15021312014389
• UDI-Public: 15021312014389
• Combination Product (Y/N): N
• Initial Reporter State: MN
• Initial Reporter Country: US
• PMA/510(K) Number: K792035
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: User Facility
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 09/03/2022

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
• Operator of Device: Health Professional
• Device Expiration Date: 01/10/2025
• Device Model Number: 35W080
• Device Catalogue Number: 35W080
• Device Lot Number: 3890129
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 03/11/2021
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/28/2022
• Initial Report FDA Received Date: 09/04/2022
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 01/22/2020
• 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
• Patient Sequence Number: 1
• Patient Sex: Unknown