MAUDE Adverse Event Report: COOK INC FREDERICK-MILLER FEEDING TUBE SET; KNT TUBES, GASTROINTESTINAL

Catalog Number	C-FMT-8.0-120
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	06/14/2016
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
This mdr is being filed after the associated complaint was reviewed under remediation protocol (b)(4), complaint/mdr retrospective review and remediation and reassessed as reportable.Additional complaint investigation and record remediation was not performed.
Event or Problem Description
The complainant reported that formula was leaking from the hub of the tube.The device was placed nasally into the jejunum and it was in place for approximately 5 months before it was removed.Aside from replacing the device, there were no additional effects to the patient reported.

• Brand Name: FREDERICK-MILLER FEEDING TUBE SET
• Common Device Name: KNT TUBES, GASTROINTESTINAL
• Manufacturer (Section D): COOK INC; 750 daniels way; bloomington IN 47404
• MDR Report Key: 7272564
• Report Number: 1820334-2018-00520
• Device Sequence Number: 1176937
• Product Code: KNT
• UDI-Device Identifier: 00827002052765
• UDI-Public: (01)00827002052765(17)180728(10)6072510
• Combination Product (Y/N): N
• Initial Reporter State: UT
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,user f
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 02/15/2018

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 Catalogue Number: C-FMT-8.0-120
• Was Device Available for Evaluation?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/14/2018
• Initial Report FDA Received Date: 02/15/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1