MAUDE Adverse Event Report: MEDLINE INDUSTRIES LP Medline; LARYNGEAL MASK, SZ 4, FLEXIBLE, DISP

Model Number	DYND300040S
Medical Device Problem Codes	Device Dislodged or Dislocated (2923); Unintended Movement (3026)
Health Effect - Clinical Code	Appropriate Clinical Signs, Symptoms and Conditions Term/Code Not Available (4581)
Date of Event	09/01/2022
Type of Reportable Event	Serious Injury
Event or Problem Description
According to the facility when repositioning the patient to a sitting position the laryngeal mask 'pops out, requiring the staff to push the device back in'.
Additional Manufacturer Narrative
According to the facility when repositioning the patient to a sitting position the laryngeal mask 'pops out, requiring the staff to push the device back in'.The sample is not available for evaluation.No additional information is available at this time.Due to the reported incident and in an abundance of caution, this medwatch is being filed.If any further relevant information is identified or obtained, a supplemental medwatch will be submitted.

• Brand Name: Medline
• Common Device Name: LARYNGEAL MASK, SZ 4, FLEXIBLE, DISP
• Manufacturer (Section D): MEDLINE INDUSTRIES LP; three lakes drive; northfield IL 60093
• Manufacturer Contact: justin herrmann ; three lakes drive; northfield, IL 60093
• MDR Report Key: 15587997
• Report Number: 1417592-2022-00190
• Device Sequence Number: 2761830
• Product Code: CAE
• UDI-Device Identifier: 10888277699526
• UDI-Public: 10888277699526
• Combination Product (Y/N): N
• Initial Reporter State: IL
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 10/12/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Health Professional
• Device Model Number: DYND300040S
• Device Catalogue Number: DYND300040S
• Device Lot Number: 59222051032
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 09/29/2022
• Initial Report FDA Received Date: 10/12/2022
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Unknown
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention
• Patient Sex: Unknown