MAUDE Adverse Event Report: SMITHS MEDICAL ASD, INC. PORTEX SUCTIONPRO 72 SL 12, SINGLE LUMEN; CATHETERS, SUCTION, TRACHEOBRONCHIAL

Catalog Number	Z115-12
Medical Device Problem Codes	Complete Blockage (1094); Disconnection (1171)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	04/01/2024
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
B3: date of event is unknown, no information has been provided to date.Investigation including root cause analysis is in progress.A supplemental mdr will be filed as necessary in accordance with 21 cfr 803.56 when additional reportable information becomes available.
Event or Problem Description
It was reported the rubber stopper got detached and was suck back to the off position.This was blocking the suction.The event occurred in the hospital during patient use.No patient harm/adverse event reported.One opened device has been returned for investigation.
Additional Manufacturer Narrative
Investigation summary: the affected device was returned for evaluation.On visual inspection there were no damage, cuts, or discrepancies affecting its performance.The sample was placed in the valve leak tester to check the assembly for leaks.No leaks were detected.The valve was activated with the thumb-valve body at different times to ensure that all components were present and activated correctly.Devices activated correctly without any difficulty.The failure mode was not confirmed.A review of the device history record (dhr) shows there were no observations or nonconformities recorded during manufacture to suggest an issue of this nature would occur with this lot of products.

• Brand Name: PORTEX SUCTIONPRO 72 SL 12, SINGLE LUMEN
• Common Device Name: CATHETERS, SUCTION, TRACHEOBRONCHIAL
• Manufacturer (Section D): SMITHS MEDICAL ASD, INC.; 6000 nathan ln n; minneapolis MN 55442
• Manufacturer Contact: reed covert ; 6000 nathan lane north; minneapolis, MN 55442 ; 2247062300
• MDR Report Key: 19332959
• Report Number: 3012307300-2024-03788
• Device Sequence Number: 6816346
• Product Code: BSY
• UDI-Device Identifier: 15019315035395
• UDI-Public: (01)15019315035395(17)251018(10)4316159
• Combination Product (Y/N): N
• Initial Reporter Country: AS
• PMA/510(K) Number: EXEMPT
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,User Facility
• Initial Reporter Occupation: Nurse
• Type of Report: Initial,Followup
• Report Date (Section B): 07/16/2024

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 Expiration Date: 10/18/2025
• Device Catalogue Number: Z115-12
• Device Lot Number: 4316159
• Was Device Available for Evaluation?: Yes
• Date Returned to Manufacturer: 04/29/2024
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/18/2024
• Supplement Date Received by Manufacturer: 06/21/2024
• Initial Report FDA Received Date: 05/16/2024
• Supplement Report FDA Received Date: 07/16/2024
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 11/08/2022
• 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