MAUDE Adverse Event Report: APPLIED MEDICAL TECHNOLOGY, INC. MINI ONE; LOW-PROFILE BALLOON BUTTON

Model Number	M1-5-1210-I
Medical Device Problem Code	No Apparent Adverse Event (3189)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	08/18/2023
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
This report is a response to mdr report # mw5145075 which was received by amt from the fda on 09/13/2023.Based on the provided information, the complaint is not a reportable event per 21 cfr section 803.There was no death.There was no serious injury, as defined by the fda.This was not life-threatening, nor did this result in permanent impairment or necessitate medical or surgical intervention to preclude permanent impairment.There was no indication of the device being available for return.Amt is currently trying to work with the reporter to see if the device can be obtained for examination.Since the device was not returned, a visual and functional evaluation could not be performed and the device failure cannot be confirmed at this time.The complaint information has been logged into our complaint database for trending purposes.
Event or Problem Description
Per the original report in mdr #: mw5145075, "failed device: button minione g-tube balloon burst.Patient required replacement of the tube with washout.".

• Brand Name: MINI ONE
• Common Device Name: LOW-PROFILE BALLOON BUTTON
• Manufacturer (Section D): APPLIED MEDICAL TECHNOLOGY, INC.; 8006 katherine boulevard; brecksville OH 44141
• Manufacturer (Section G): APPLIED MEDICAL TECHNOLOGY, INC.; 8006 katherine boulevard; brecksville OH 44141
• Manufacturer Contact: joshua meinke ; 8006 katherine boulevard; brecksville, OH 44141 ; 4407174000
• MDR Report Key: 17928086
• Report Number: 1526012-2023-00009
• Device Sequence Number: 6359043
• Product Code: KNT
• UDI-Device Identifier: 00842071113827
• UDI-Public: 00842071113827
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K161413
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Explanted Year: 2023
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 10/12/2023

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
• Device Expiration Date: 09/01/2025
• Device Model Number: M1-5-1210-I
• Device Catalogue Number: M1-5-1210-I
• Device Lot Number: 221118-437
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 09/13/2023
• Initial Report FDA Received Date: 10/12/2023
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 11/18/2022
• 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
• Usage of Device: Initial
• Patient Sequence Number: 1
• Patient Sex: Unknown