MAUDE Adverse Event Report: MALLINCKRODT MEDICAL SHILEY; TUBE, BRONCHIAL (W/WO CONNECTOR)

Model Number	126035
Medical Device Problem Code	Deflation Problem (1149)
Health Effect - Clinical Code	Extubate (2402)
Date of Event	06/06/2017
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
A good faith effort will be made to obtain the applicable information relevant to the report.If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
Medtronic received a communication that an endobronchial tube failed to inflate or deflate.It was reported that a second device was required.
Additional Manufacturer Narrative
The sample was returned and visual examination showed that the shape returned unit had been altered using the stylet wire.The stylet wire was removed and inflation/deflation testing was successful.There was no fault found with the device.The probable root cause is that the cuff test was carried out when the shape of the tube was incorrectly altered with the stylet wire.If information is provided in the future, a supplemental report will be issued.

• Brand Name: SHILEY
• Common Device Name: TUBE, BRONCHIAL (W/WO CONNECTOR)
• Manufacturer (Section D): MALLINCKRODT MEDICAL; cornamaddy; athlone 3810
• MDR Report Key: 6676062
• Report Number: 8020889-2017-05067
• Device Sequence Number: 13470918
• Product Code: BTS
• UDI-Device Identifier: 30884522028954
• UDI-Public: 30884522028954
• Combination Product (Y/N): N
• Initial Reporter Country: CA
• PMA/510(K) Number: K771219
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: consumer,foreign,user facilit
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 12/04/2017

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Expiration Date: 11/01/2021
• Device Model Number: 126035
• Device Catalogue Number: 126035
• Device Lot Number: 201611420X
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 12/04/2017
• Initial Date Received by Manufacturer: 06/06/2017
• Supplement Date Received by Manufacturer: 12/04/2017
• Initial Report FDA Received Date: 06/28/2017
• Supplement Report FDA Received Date: 12/04/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention