MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION Resolution 360? ULTRA Clip; Hemostatic Metal Clip for the GI Tract

Model Number	M00521400
Medical Device Problem Code	Premature Activation (1484)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	08/19/2026
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported to boston scientific corporation that a resolution 360 ultra clip was used during a mucosectomy at an unknown anatomical location in a procedure performed on (b)(6) 2026.During the procedure, while the clip was being positioned, it detached without having been released.The procedure was completed.No information regarding how the procedure was completed was provided.There were no reported patient complications.
Additional Manufacturer Narrative
Block h6: imrdf code a150103 captures the reportable event of clip premature deployment (egd/unknown anatomy).

• Brand Name: Resolution 360? ULTRA Clip
• Common Device Name: Hemostatic Metal Clip for the GI Tract
• 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 ; +1(914)571-6918
• MDR Report Key: 50803765
• Report Number: 3005099803-2026-03833
• Device Sequence Number: 10544451
• Product Code: PKL
• UDI-Device Identifier: 08714729997245
• UDI-Public: (01)08714729997245(17)270930(10)34958406
• Combination Product (Y/N): N
• Initial Reporter State: 15
• Initial Reporter Country: PE
• PMA/510(K) Number: K222503
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Other,Foreign,Health Professional,Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 09/17/2026

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: M00521400
• Device Catalogue Number: M00521400
• Device Lot Number: 0034958406
• 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: 08/24/2026
• Initial Report FDA Received Date: 09/17/2026
• Date Device Manufactured: 09/30/2024
• 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
• Patient Sex: Unknown