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 Code	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 performed.No problems or issues were identified during the dhr review.Seven samples were received for evaluation.Visual testing was performed.Visual inspection found the pouch seals revealed an opening on the bottom seal on each pouch.The root cause of the issue could not be determined.An internal non-conformance report (ncr) has been opened to address the multiple complaints received by a single complainant.This issue will be monitored for any increase in occurrence.If the occurrence of this issue increases significantly, additional investigative action will be taken accordingly.This remediation mdr was generated under protocol (b)(4), as a result of warning letter cms# 617147.
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: 15353779
• Report Number: 3012307300-2022-17613
• Device Sequence Number: 6023267
• 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: 11/09/2025
• Device Model Number: 35W080
• Device Catalogue Number: 35W080
• Device Lot Number: 4060252
• 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
• 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