MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION RESOLUTION CLIP CLIPPING DEVICE; CLIP, HEMOSTATIC

Model Number	M00522612
Medical Device Problem Code	Premature Activation (1484)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	02/13/2026
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Block h6: imrdf code a150103 captures the reportable event of premature deployment, egd or unknown procedure, also unknown location or esophagus.
Event or Problem Description
It was reported to boston scientific corporation that a resolution clip was used during an egd (esophagogastroduodenoscopy) procedure performed on (b)(6) 2026.During the procedure, the clip prematurely deployed in unknown location.The procedure was completed with an alternative device.There were no patient complications reported as a result of this event.No further information was obtained despite good faith efforts.Note: this report pertains to one of five clips used.
Additional Manufacturer Narrative
Block h6: imrdf code a150103 captures the reportable event of premature deployment, egd or unknown procedure, also unknown location or esophagus.Correction: b5: describe event or problem.E1: initial reporter email.E1: initial reporter fax.Block h11: investigation results: the resolution clip was not returned for analysis.The device was implanted; therefore, a technical analysis could not be performed.A review was completed of the device history record (dhr) for the device.It was confirmed this device met manufacturing specifications prior to distribution and there were no manufacturing deviations which could have contributed to the reported event.Based on the thorough review of the reported complaint, boston scientific has assigned an investigation conclusion code of unable to exclude device problem.
Event or Problem Description
It was reported to boston scientific corporation that a resolution clip was used during an egd (esophagogastroduodenoscopy) procedure performed on (b)(6) 2026.During the procedure, the clip prematurely deployed.The anatomy location is unknown.The procedure was completed with an alternative device.There were no patient complications reported as a result of this event.No further information was obtained despite good faith efforts.Note: this report pertains to three of five clips used.

• Brand Name: RESOLUTION CLIP CLIPPING DEVICE
• Common Device Name: CLIP, HEMOSTATIC
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; 300 boston scientific way; marlborough MA 01752
• Manufacturer (Section G): BOSTON SCIENTIFIC CORPORATION; 2546 calle primera; alajuela ; CS
• Manufacturer Contact: christina lam ; 300 boston scientific way; marlborough, MA 01752 ; 9145716918
• MDR Report Key: 24531287
• Report Number: 3005099803-2026-00851
• Device Sequence Number: 9071246
• Product Code: PKL
• UDI-Device Identifier: 08714729504818
• UDI-Public: (01)08714729504818(17)281208(10)38145963
• Combination Product (Y/N): N
• Initial Reporter State: OR
• Initial Reporter Country: US
• PMA/510(K) Number: K222503
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Health Professional,Company Representative
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 03/13/2026

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: M00522612
• Device Catalogue Number: 2261
• Device Lot Number: 0038145963
• 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: 02/16/2026
• Supplement Date Received by Manufacturer: 03/05/2026
• Initial Report FDA Received Date: 03/06/2026
• Supplement Report FDA Received Date: 03/13/2026
• Date Device Manufactured: 12/09/2025
• 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