MAUDE Adverse Event Report: BOSTON SCIENTIFIC CORPORATION FLEXIMA APDL; TUBE, DRAINAGE, SUPRAPUBIC

Model Number	30935
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	05/28/2019
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that the device detached near the hub.A 12 flexima apdl drainage catheter was used in a chest tube in the right pleural space for effusion.However, it was noted that the device came apart near the hub.The device was then removed and a new device was implanted into the patient.No complications were reported and the patient was stable.The patient will likely to return within the next 1-2 weeks time for subsequent tube removals.
Additional Manufacturer Narrative
Age at time of event- 64 years old.Device evaluated by mfr.: the device was returned for analysis.The catheter returned has the hub detached of the device and the heat shrink was received properly attached to the catheter.The flare of the device was found formed.Additionally, the catheter returned with the working length cut/detached at 8.5 cm from the proximal section (heat shrink).
Event or Problem Description
It was reported that the device detached near the hub.A 12 flexima apdl drainage catheter was used in a chest tube in the right pleural space for effusion.However, it was noted that the device came apart near the hub.The device was then removed and a new device was implanted into the patient.No complications were reported and the patient was stable.The patient will likely to return within the next 1-2 weeks time for subsequent tube removals.

• Brand Name: FLEXIMA APDL
• Common Device Name: TUBE, DRAINAGE, SUPRAPUBIC
• Manufacturer (Section D): BOSTON SCIENTIFIC CORPORATION; two scimed place; maple grove MN 55311
• MDR Report Key: 8722093
• Report Number: 2134265-2019-07253
• Device Sequence Number: 19253603
• Product Code: FFA
• UDI-Device Identifier: 08714729323143
• UDI-Public: 08714729323143
• Combination Product (Y/N): N
• Initial Reporter State: WI
• Initial Reporter Country: US
• PMA/510(K) Number: K944290
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2019
• Device Explanted Year: 2019
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 08/02/2019

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: 03/25/2022
• Device Model Number: 30935
• Device Catalogue Number: 30935
• Device Lot Number: 0023543511
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 06/11/2019
• Initial Date Received by Manufacturer: 05/29/2019
• Supplement Date Received by Manufacturer: 07/08/2019
• Initial Report FDA Received Date: 06/21/2019
• Supplement Report FDA Received Date: 08/02/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 64 YR