MAUDE Adverse Event Report: SMITHS MEDICAL ASD, INC. BIVONA; CUSTOMIZED TRACHESTOMY TUBE

Model Number	HT17HS70NSC122N
Medical Device Problem Code	Inflation Problem (1310)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The sample was received for evaluation.The lot number of the reported device was not provided therefore no device history review (dhr) could be performed.Visual and functional testing were performed and the reported issue could not be confirmed.During visual inspection, no damage to the sample was observed.During functional testing, the sample was found to pass the inflation testing.Manufacturing controls are in place to help prevent occurrence of the reported issue.The root cause of the reported issue could not be determined.Operator of device is patient/consumer.If initial reporter also sent report to fda is no.This remediation mdr was generated under protocol (b)(4), as a result of warning letter cms# (b)(4).
Event or Problem Description
It was reported that during pre-test, the cuff was found asymmetrical.No patient involvement.

• Brand Name: BIVONA
• Common Device Name: CUSTOMIZED TRACHESTOMY TUBE
• 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: 15446886
• Report Number: 3012307300-2022-19663
• Device Sequence Number: 7709191
• Product Code: JOH
• UDI-Device Identifier: 15019517120783
• UDI-Public: 15019517120783
• Combination Product (Y/N): N
• Initial Reporter Country: NL
• PMA/510(K) Number: K923878
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Consumer
• Initial Reporter Occupation: Administrator/Supervisor
• Type of Report: Initial
• Report Date (Section B): 09/19/2022

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: Lay User/Patient
• Device Model Number: HT17HS70NSC122N
• Device Catalogue Number: HT17HS70NSC122N
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 06/07/2021
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 07/10/2022
• Initial Report FDA Received Date: 09/19/2022
• 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