MAUDE Adverse Event Report: SMITHS MEDICAL INTERNATIONAL, LTD. PORTEX GENERAL ANESTHESIA CIRCUITS; TUBE, TRACHEOSTOMY (W/WO CONNECTOR)

Catalog Number C37101329-NLJ

Device Problem Break (1069)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Date 10/01/2019

Event Type  malfunction  

Manufacturer Narrative

(udi) and (510k) are unknown; no additional information was provided.This mdr was generated under protocol b10009704, as a result of warning letter cms#: 617147.No lot number was provided; therefore, a device history record (dhr) review could not be completed.The sample was received in used conditions without its original packaging.Visual inspection: the sample was visually inspected at a distance of 12 inches under normal lighting to received unit; the breathing bag had a pinhole.The most probable root cause of the issue was deemed to be manufacturing-related; production personnel did not detect and scrapped the damaged breathing bag.Action(s) taken to mitigate the reported issue(s): qalert was generated to ensure that production personnel detect any missing component.Production personnel was trained in this qalert.

Event Description

It was reported that, during a pre-use check, the customer found a tear in the anesthesia bag.No patient injury was reported.

• Brand Name: PORTEX GENERAL ANESTHESIA CIRCUITS
• Type of Device: TUBE, TRACHEOSTOMY (W/WO CONNECTOR)
• Manufacturer (Section D): SMITHS MEDICAL INTERNATIONAL, LTD.; boundary road; hythe, kent CT21 6JL; UK CT21 6JL
• Manufacturer (Section G): SMITHS MEDICAL INTERNATIONAL, LTD.; boundary road; hythe, kent CT21 6JL; UK CT21 6JL
• Manufacturer Contact: jim vegel ; 6000 nathan lane north; 2-12-12 kitanagase-omote-machi; minneapolis, MN 55442
• MDR Report Key: 15650254
• MDR Text Key: 306931364
• Report Number: 3012307300-2022-25673
• Device Sequence Number: 1
• Product Code: BTO
• Combination Product (y/n): N
• Reporter Country Code: JA
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Foreign,User Facility
• Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date: 10/21/2022

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 10/21/2022
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Catalogue Number: C37101329-NLJ
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 10/11/2019
• Was the Report Sent to FDA?: No
• Date Manufacturer Received: 09/29/2022
• Was Device Evaluated by Manufacturer?: Yes
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1