MAUDE Adverse Event Report: MMJ SA DE CV (USD) MALLINCKRODT; TUBE, TRACHEAL (W/WO CONNECTOR)

Model Number	18785
Medical Device Problem Code	Inflation Problem (1310)
Health Effect - Clinical Code	No Patient Involvement (2645)
Date of Event	11/01/2018
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
According to the reporter, upon inflation, the device's cuff did not stay inflated.It was reported that the test was redone prior to removal of the tube from packaging for further review.Customer reported that there was no patient involvement.
Additional Manufacturer Narrative
Evaluation summary: one sample device was received for evaluation.The reported event in cuff was confirmed.The visual inspection was performed, and it was observed the cuff presents a cut.An inflation/deflation test was performed and it was observed the cuff deflated immediately.Information has been added to the database and trends will continue to be monitored.If information is provided in the future, a supplemental report will be issued.
Additional Manufacturer Narrative
If information is provided in the future, a supplemental report will be issued.

• Brand Name: MALLINCKRODT
• Common Device Name: TUBE, TRACHEAL (W/WO CONNECTOR)
• Manufacturer (Section D): MMJ SA DE CV (USD); ave henequen no 1181 desarroll; ciudad juarez 32590 ; MX 32590
• MDR Report Key: 8109036
• Report Number: 2936999-2018-00737
• Device Sequence Number: 16661403
• Product Code: BTR
• UDI-Device Identifier: 10884522007627
• UDI-Public: 10884522007627
• Combination Product (Y/N): N
• Initial Reporter Country: AS
• PMA/510(K) Number: K090352
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,foreig
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 04/04/2019

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 Expiration Date: 05/08/2023
• Device Model Number: 18785
• Device Catalogue Number: 18785
• Device Lot Number: 18E0272JZX
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 01/04/2019
• Initial Date Received by Manufacturer: 11/02/2018
• Supplement Date Received by Manufacturer: 02/06/2019; 03/15/2019
• Initial Report FDA Received Date: 11/27/2018
• Supplement Report FDA Received Date: 03/02/2019; 04/04/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1