MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION ENDOVIVE SAFETY PEG KIT; TUBES, GASTROINTESTINAL (AND ACCESSORIES)

Model Number	M00566490
Medical Device Problem Code	Detachment of Device or Device Component (2907)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	01/08/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).The device has been received for analysis.Upon completion of the failure analysis of the complaint device, if there is any further relevant information from that review, a supplemental medwatch will be filed.
Event or Problem Description
It was reported to boston scientific corporation that an endovive safety peg kit push method was used during a percutaneous endoscopic gastrostomy (peg) placement procedure on (b)(6) 2019.  according to the complainant, during the procedure, the peg tube detached at the transition zone between the hard and soft plastic when it was inserted into the abdomen.The procedure was completed with a new endovive safety peg kit push method.  there were no patient complications reported as a result of this event.
Additional Manufacturer Narrative
Problem code 2907 captures the reportable event of feeding tube detached.Visual examination of the returned device revealed that the peg tube was separated.Residue was present on both interfaces of the transition joint between the peg tube and introducer dilator.The complaint wass consistent with the reported event of feeding tube separated.It is likely that several factors, such as user technique/handling, patient anatomy, and the size of the incision site that the tube is being pulled through, contributed to the reported complaint.Therefore, the complaint investigation conclusion code selected is adverse event related to procedure, which indicates that the adverse event occurred during the procedure and the device had no influence on the event.A dhr (device history record) review was performed and no deviation was found.A labeling review was performed and no anomalies were found.
Event or Problem Description
It was reported to boston scientific corporation that an endovive safety peg kit push method was used during a percutaneous endoscopic gastrostomy (peg) placement procedure on (b)(6) 2019.According to the complainant, during the procedure, the peg tube detached at the transition zone between the hard and soft plastic when it was inserted into the abdomen.The procedure was completed with a new endovive safety peg kit push method.There were no patient complications reported as a result of this event.

• Brand Name: ENDOVIVE SAFETY PEG KIT
• Common Device Name: TUBES, GASTROINTESTINAL (AND ACCESSORIES)
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; 300 boston scientific way; marlborough MA 01752
• MDR Report Key: 8281968
• Report Number: 3005099803-2019-00297
• Device Sequence Number: 1234168
• Product Code: KNT
• UDI-Device Identifier: 08714729748410
• UDI-Public: 08714729748410
• Combination Product (Y/N): N
• Initial Reporter State: HI
• Initial Reporter Country: US
• PMA/510(K) Number: K031538
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 04/09/2019

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: 04/30/2019
• Device Model Number: M00566490
• Device Catalogue Number: 6649
• Device Lot Number: 0021819975
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 01/15/2019
• Initial Date Received by Manufacturer: 01/08/2019
• Supplement Date Received by Manufacturer: 03/17/2019
• Initial Report FDA Received Date: 01/28/2019
• Supplement Report FDA Received Date: 04/09/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1