MAUDE Adverse Event Report: SMITHS MEDICAL ASD; INC. BIVONA® ADULT TTS¿ HYPERFLEX¿ TRACHEOSTOMY TUBE; TUBE TRACHEOSTOMY AND TUBE CUFF

Catalog Number	67HA90
Medical Device Problem Codes	Leak/Splash (1354); Scratched Material (3020)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	10/02/2019
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
One pneupac ventilator was returned in good condition.The unit was turned on for functional testing and was observed to be working as intended.Based on the evidence, the complaint was not confirmed.One bivona® adult tts¿ hyperflex¿ tracheostomy tube was returned for analysis.Visual inspection revealed a black piece of tape was found on the cuff and two marks on the cuff.The cuff was then inflated with air but was observed to deflate within one minute.The device was then put through leak testing; the leak was found to be leaking near the right side of the tape.Magnification was used to inspect the cuff; abrasions were found on the cuff.Based on the evidence the complaint was confirmed.The root cause was found to be user interface as the abrasions were likely due to repossessing.
Event or Problem Description
Information was received indicating that the cuff to a smiths medical bivona® adult tts¿ hyperflex¿ tracheostomy tube was found to be broken six hours after use.It was reported that the tube had been removed for repossessing prior to reinsertion.The trach tube was removed and returned.There were no reported adverse patient effects.

• Brand Name: BIVONA® ADULT TTS¿ HYPERFLEX¿ TRACHEOSTOMY TUBE
• Common Device Name: TUBE TRACHEOSTOMY AND TUBE CUFF
• Manufacturer (Section D): SMITHS MEDICAL ASD; INC.; 6000 nathan lane n; minneapolis, MN 55442
• MDR Report Key: 9304976
• Report Number: 3012307300-2019-06307
• Device Sequence Number: 1865083
• Product Code: JOH
• UDI-Device Identifier: 15021312013825
• UDI-Public: 15021312013825
• Combination Product (Y/N): N
• Initial Reporter Country: TW
• PMA/510(K) Number: K081440
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: distributor,foreign
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 11/11/2019

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Operator of Device: No Information
• Device Catalogue Number: 67HA90
• Device Lot Number: 2081250
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 10/31/2019
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 10/24/2019
• Initial Report FDA Received Date: 11/11/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention