MAUDE Adverse Event Report: SMITHS MEDICAL ASD, INC. BIVONA PEDIATRIC TTS TRACHEOSTOMY TUBE; TUBE TRACHEOSTOMY AND TUBE CUFF

Model Number	67SP030
Medical Device Problem Code	Inflation Problem (1310)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	04/03/2020
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that during a hospital pre-test, of a tracheostomy tube, the cuff failed.No patient injury was reported.
Additional Manufacturer Narrative
One used sample was received to perform an investigation.A device history record (dhr) review was conducted which indicated all inspections were completed and no issues were noted during manufacture.A visual inspection was performed at 12 inches from the device under normal lighting to detect any damage on the cuff, airline or pilot balloon.No damage could be detected.Functional testing was performed by filling the device with 5cc of air.The pilot balloon inflated but the air got stuck.The cuff was manipulated and then the whole cuff inflated.The reported problem was not confirmed.The instructions for use (ifu) inform the user to attach a syringe to the pilot balloon and slowly inflate the cuff with 5ml of sterile water.If the cuff does not inflate completely, squeeze the pilot balloon while gently manipulating the cuff from the shaft.If the cuff still does not inflate, use a new tube.As a preventive action production personnel were notified by quality engineer of the defect reported by the customer.No root cause could be determined as the complaint could not be confirmed.This remediation mdr was generated under protocol b10009406, as a result of warning letter cms# 617147.

• Brand Name: BIVONA PEDIATRIC TTS TRACHEOSTOMY TUBE
• Common Device Name: TUBE TRACHEOSTOMY AND TUBE CUFF
• 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: 15443207
• Report Number: 3012307300-2022-19555
• Device Sequence Number: 20232660
• Product Code: JOH
• UDI-Device Identifier: 15021312000696
• UDI-Public: 15021312000696
• Combination Product (Y/N): N
• Initial Reporter State: MA
• Initial Reporter Country: US
• PMA/510(K) Number: K914088
• 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): 09/17/2022

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: 02/16/2024
• Device Model Number: 67SP030
• Device Catalogue Number: 67SP030
• Device Lot Number: 3763964
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 04/16/2020
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 07/15/2022
• Initial Report FDA Received Date: 09/17/2022
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 04/26/2019
• 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