MAUDE Adverse Event Report: MEDLINE INDUSTRIES LP; TUBE,GASTROSTOMY,16FR,3-PORT,ENFIT

Catalog Number	ENFIT70316
Medical Device Problem Code	Material Integrity Problem (2978)
Health Effect - Clinical Code	Appropriate Clinical Signs, Symptoms and Conditions Term/Code Not Available (4581)
Date of Event	08/28/2023
Type of Reportable Event	Malfunction
Event or Problem Description
Tube slid out and required replacement.
Additional Manufacturer Narrative
It was reported by the customer contact that on, " patient came in on (b)(6) to have a g-tube replaced.Patient came back on (b)(6) upset and reported the g-tube had slide out.A replacement was placed in real time".It was reported that the tube was replaced in "ir".There was no injury reported related to the incident.A sample was requested to be returned for evaluation.It has been determined that the reported event could cause or contribute to serious injury if it were to occur.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.

• Common Device Name: TUBE,GASTROSTOMY,16FR,3-PORT,ENFIT
• Manufacturer (Section D): MEDLINE INDUSTRIES LP; three lakes drive; northfield IL 60093
• Manufacturer Contact: kelly zampella ; three lakes drive; northfield, IL 60093
• MDR Report Key: 17814040
• Report Number: 1417592-2023-00388
• Device Sequence Number: 14998311
• Product Code: PIF
• UDI-Device Identifier: 10888277411043
• UDI-Public: 10888277411043
• Combination Product (Y/N): N
• Initial Reporter State: MI
• 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): 09/25/2023

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
• Device Catalogue Number: ENFIT70316
• Device Lot Number: 1106108
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 09/12/2023
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 08/28/2023
• Initial Report FDA Received Date: 09/25/2023
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• 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: Other
• Patient Sex: Unknown