MAUDE Adverse Event Report: AVANOS MEDICAL INC. MIC* JEJUNOSTOMY FEEDING TUBE, 14 FR; DH EF JEJUNOSTOMY PRODUCTS

Model Number	0301-14
Medical Device Problem Code	Detachment of Device or Device Component (2907)
Health Effect - Clinical Code	Device Embedded In Tissue or Plaque (3165)
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The actual complaint product was not returned for evaluation.Root cause could not be determined.A review of the device history record is not possible as no lot number was provided.All information reasonably known as of 19 mar 2019 has been included in this health authority report.Should additional information be obtained, a follow-up health authority report will be provided.The information provided by avanos medical inc.Represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to avanos medical inc.Avanos medical inc.Has no independent knowledge of the event reported but is relaying the information that was provided by the user facility where the incident occurred.This product incident is documented in the halyard health complaint database and identified as complaint (b)(4).Device not received.
Event or Problem Description
It was reported that the tube was removed from the patient, however, the cuff of the tube remained behind in the patient.The remaining piece was visualized by ct scan.As there were no signs of infection and the fragile nature of the patient, it was determined to leave the cuff in situ.No further information provided.

• Common Device Name: DH EF JEJUNOSTOMY PRODUCTS
• Manufacturer (Section D): AVANOS MEDICAL INC.; 5405 windward parkway; alpharetta GA 30004
• MDR Report Key: 8433204
• Report Number: 9611594-2019-00055
• Device Sequence Number: 13718688
• Product Code: KNT
• UDI-Device Identifier: 10680651956771
• UDI-Public: 10680651956771
• Combination Product (Y/N): N
• Initial Reporter Country: UK
• PMA/510(K) Number: K844745
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: distributor,foreign,other,use
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 03/07/2019

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Model Number: 0301-14
• Device Catalogue Number: 991095677
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/07/2019
• Initial Report FDA Received Date: 03/19/2019
• Patient Sequence Number: 1