MAUDE Adverse Event Report: FISHER & PAYKEL HEALTHCARE LTD FISHER AND PAYKEL HEALTHCARE; NASAL CANNULA

Model Number	OJR412B
Medical Device Problem Code	Detachment of Device or Device Component (2907)
Health Effect - Clinical Code	Low Oxygen Saturation (2477)
Type of Reportable Event	Malfunction
Event or Problem Description
A distributor in japan reported, on behalf of a healthcare facility, that the tubing of an optiflow junior 2 nasal cannula, as part of the ojr412b optiflow junior 2 nasal interface blender transition kit s, was detached from the cannula.The healthcare facility reported that the patient experienced a minor oxygen desaturation, with the lowest recorded level around 90% spo2.The cannula was subsequently replaced to maintain therapy, after which the patient condition promptly stabilised.There were no further reported patient consequences, and the patient has since been discharged from hospital.
Additional Manufacturer Narrative
(b)(4).Fisher & paykel healthcare (f&p) is currently in the process of completing our investigation.We will provide a follow up report upon completion of our investigation.
Additional Manufacturer Narrative
(b)(6).Method: the subject device, ojr412b optiflow junior 2 nasal interface blender transition kit was returned to fisher & paykel healthcare (f&p) in new zealand for evaluation.Our investigation is based on the analysis of the returned device, and our knowledge of the product.Results: visual inspection of the subject device confirmed that both tubes were detached from the cannula.Conclusion: based on the visual inspection of the returned device, and our knowledge of the product, it is most likely that the reported event resulted from the cannula being subjected to excessive force.As part of the manufacturing process, all optiflow junior cannulas are 100% leak and occlusion tested after final assembly and any cannula that fails specifications is discarded.In addition, representative samples from each batch are functionally tested to assess retention strength between the assembled components.If there are any failures the entire batch quarantined for further investigation.The user instructions which accompany the ojr412b optiflow junior 2 nasal interface blender transition kit show in pictorial format the correct placement and fitting of the cannula, and provide the following warnings: - "appropriate patient monitoring (e.G., oxygen saturation) must be used at all times.Failure to monitor the patient (e.G.In the event of an interruption to gas flow) may result in serious injury or death." - "ensure all connections are secure during use.Check the cannula is undamaged and that the flow path is maintained.Under excessive load, the cannula may disconnect to prevent forces being transferred to the patient." - "do not stretch the cannula on application; this may cause increase pressure to the patient's skin.If necessary, the cannula may be repositioned.".
Event or Problem Description
A distributor in japan reported, on behalf of a healthcare facility, that the tubing of an optiflow junior 2 nasal cannula, as part of the ojr412b optiflow junior 2 nasal interface blender transition kit s, was detached from the cannula.The healthcare facility reported that the patient experienced a minor oxygen desaturation, with the lowest recorded level around 90% spo2.The cannula was subsequently replaced to maintain therapy, after which the patient condition promptly stabilised.There were no further reported patient consequences, and the patient has since been discharged from hospital.

• Brand Name: FISHER AND PAYKEL HEALTHCARE
• Common Device Name: NASAL CANNULA
• Manufacturer (Section D): FISHER & PAYKEL HEALTHCARE LTD; 15 maurice paykel place; east tamaki; auckland, 2013 ; NZ 2013
• Manufacturer (Section G): FISHER & PAYKEL HEALTHCARE LTD; 15 maurice paykel place; east tamaki; auckland, 2013 ; NZ 2013
• Manufacturer Contact: diego vargas banuelos ; 17400 laguna canyon road; suite 300; irvine, CA 92618 ; 9494341005
• MDR Report Key: 22787576
• Report Number: 9611451-2025-00751
• Device Sequence Number: 8256858
• Product Code: BTT
• UDI-Device Identifier: 09420012448859
• UDI-Public: (01)09420012448859(10)2103162519(11)240530(17)270530
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K222197
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,User Facility,Distributor
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 10/22/2025

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: OJR412B
• Device Catalogue Number: OJR412B
• Device Lot Number: 2103162519
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 07/14/2025
• Supplement Date Received by Manufacturer: 09/30/2025
• Initial Report FDA Received Date: 08/12/2025
• Supplement Report FDA Received Date: 10/21/2025
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 05/30/2024
• 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
• Concomitant Medical Products and Therapy/Usage Dates: FABIAN NIV; FABIAN NIV; MR850 - HEATED HUMIDIFIER; MR850 - HEATED HUMIDIFIER; RT132 INFANT CONTINUOUS FLOW CIRCUIT; RT132 INFANT CONTINUOUS FLOW CIRCUIT
• Patient Age: 21 DA
• Patient Sex: Unknown