MAUDE Adverse Event Report: AVANOS MEDICAL INC. AVANOS MEDICAL, INC; BALLARD INTUBATION KIT

Model Number	92426
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	Appropriate Clinical Signs, Symptoms and Conditions Term/Code Not Available (4581)
Date of Event	01/13/2025
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
H6: (appropriate health effect-clinical code (e) not available): infusion/flow problem.It was reported, the product involved in the report is not available for return.A review of the device history record is in-progress.All information reasonably known as of 02 apr 2025 has been included in this health authority report.Should additional information be obtained, a follow-up health authority report will be provided.The information provided by sun med holdings llc.Represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to sun med holdings llc.Sun med holdings llc.Has no independent knowledge of the event reported but is relaying the information that was provided by the user facility where the incident occurred.This product incident is documented in the sun med holdings complaint database and identified as (b)(4).This information is submitted pursuant to 21cfr803, in compliance with the medical device reporting requirement and should not be considered to be an admission that an sun med holdings llc.Product is defective or caused serious injury.
Event or Problem Description
It was reported, the inline y-catheter broke in two and was stuck in the endotracheal tube of the patient which caused the patient's ventilation to stop.The nursing team emergently cut the patient's endotracheal tube and placed a new inline y-catheter into the endotracheal tube.There was no reported injury.
Additional Manufacturer Narrative
Correction: g1.Investigation results: d4; h6.Additional information: na.H6: (appropriate health effect-clinical code (e) not available): infusion/flow problem.The product involved in the report was not available for return.Additionally, no photographs or video evidence was provided.Without a sample/photograph and or video evidence to evaluate the root cause could not be determined.The device history record for lot 30202150 was reviewed and the product was produced according to product specifications.All information reasonably known as of 24 jun 2025 has been included in this health authority report.Should additional information be obtained, a follow-up health authority report will be provided.The information provided by sun med holdings llc.Represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to sun med holdings llc.Sun med holdings llc.Has no independent knowledge of the event reported but is relaying the information that was provided by the user facility where the incident occurred.This product incident is documented in the sun med holdings complaint database and identified as complaint-(b)(4).This information is submitted pursuant to 21cfr803, in compliance with the medical device reporting requirement and should not be considered to be an admission that an sun med holdings llc.Product is defective or caused serious injury.
Event or Problem Description
It was reported, the inline y-catheter broke in two and was stuck in the endotracheal tube of the patient which caused the patient's ventilation to stop.The nursing team emergently cut the patient's endotracheal tube and placed a new inline y-catheter into the endotracheal tube.There was no reported injury.

• Brand Name: AVANOS MEDICAL, INC
• Common Device Name: BALLARD INTUBATION KIT
• Manufacturer (Section D): AVANOS MEDICAL INC.; 5405 windward parkway; alpharetta GA 30004
• Manufacturer (Section G): AVENT S DE RL DE CV; carretera internacional; salida norte no. 1053; magdalena, mx 84160 ; MX 84160
• Manufacturer Contact: racheal cooper ; 2710 north ridge dr nw; ste a; grand rapids, MI 49544
• MDR Report Key: 21751840
• Report Number: 8030647-2025-00040
• Device Sequence Number: 12812099
• Product Code: BSY
• UDI-Device Identifier: 00609038924267
• UDI-Public: (01)00609038924267(10)30202150(17)270606(240)120004461
• Combination Product (Y/N): N
• Initial Reporter Country: CA
• 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,User Facility
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 06/24/2025

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: 92426
• Device Catalogue Number: 19035
• Device Lot Number: 30202150
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/05/2025
• Supplement Date Received by Manufacturer: 05/26/2025
• Initial Report FDA Received Date: 04/02/2025
• Supplement Report FDA Received Date: 06/24/2025
• Was Device Evaluated by Manufacturer? (Y/N): No
• 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: Unknown
• Patient Sequence Number: 1
• Patient Age: 14 DA
• Patient Sex: Unknown