MAUDE Adverse Event Report: JIANGSU JIANYU HEALTH MEDICAL CO LTD BLOX; ENDOSCOPIC BITE BLOCK

Model Number	SBT-114-100
Medical Device Problem Code	Material Separation (1562)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	11/02/2023
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Block h6: imdrf device code a0413 captures the reportable event of bite blox material separation.
Event or Problem Description
It was reported to boston scientific corporation that a bite blox was used during an upper gastrointestinal endoscopy performed on (b)(6) 2023.During the procedure, when the endoscope was inserted a snapping sound was heard.A broken piece was found inside the mouth and recovered.There were no oral lacerations.The procedure was completed with another bite blox.There were no patient complication as a result of this event.
Additional Manufacturer Narrative
Block h6: imdrf device code a0413 captures the reportable event of bite blox material separation.Block h10: investigation results the returned bite blox was analyzed.Visual evaluation found that the bite blox housing was damaged.A piece of the device in the bite region was broken off, and the presence of bite marks was noted.No other problems were noted.The reported event was confirmed.Product analysis identified that the device had a broken bite piece.It is likely that a compressive bite force caused the bite blox housing to be damaged, as evidenced by the presence of bite marks.Based on all available information and analysis of the returned device, the most probable cause is adverse event related to procedure.
Event or Problem Description
It was reported to boston scientific corporation that a bite blox was used during an upper gastrointestinal endoscopy performed on (b)(6) 2023.During the procedure, when the endoscope was inserted a snapping sound was heard.A broken piece was found inside the mouth and recovered.There were no oral lacerations.The procedure was completed with another bite blox.There were no patient complication as a result of this event.

• Brand Name: BLOX
• Common Device Name: ENDOSCOPIC BITE BLOCK
• Manufacturer (Section D): JIANGSU JIANYU HEALTH MEDICAL CO LTD; zhixi industry zone; jintan area; changzhou city 21325 1; CH 213251
• Manufacturer (Section G): JIANGSU JIANYU HEALTH MEDICAL CO LT; no 88 of longxi avenue; zhulin town; changzhou city 21324 1; CH 213241
• Manufacturer Contact: carole morley ; 300 boston scientific way; marlborough, MA 01752 ; 5086834015
• MDR Report Key: 18273498
• Report Number: 3005099803-2023-06418
• Device Sequence Number: 5540982
• Product Code: MNK
• UDI-Device Identifier: 00816849010168
• UDI-Public: 00816849010168
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: EXEMPT
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Other,Foreign,Health Professional,Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 02/07/2024

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: Health Professional
• Device Model Number: SBT-114-100
• Device Catalogue Number: SBT-114-100
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 11/07/2023
• Supplement Date Received by Manufacturer: 01/12/2024
• Initial Report FDA Received Date: 12/06/2023
• Supplement Report FDA Received Date: 02/07/2024
• 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
• Usage of Device: Initial
• Patient Sequence Number: 1
• Patient Sex: Unknown