MAUDE Adverse Event Report: AVANOS MEDICAL INC. LAPAROSCOPIC INTRODUCER KIT FOR GASTROSTOMY FEEDING TUBE, 22 FR DILATOR; DH EF PERC PLACEMENT PRODUCTS

Model Number	10237
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	11/18/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The actual complaint product was not returned for evaluation.A review of the device history record is not possible as no lot number was provided.Root cause could not be determined.All information reasonably known as of 13-dec-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.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 avanos medical, inc.Complaint database and identified as complaint (b)(4).
Event or Problem Description
Avanos medical, inc.Received a single report that referenced three different incidences, which were associated with separate units, involving three different events.This is the second of three reports.Refer to 9611594-2019-00250 for the first event.Refer to 9611594-2019-00252 for the third event.It was reported the trans abdominal bolsters are falling off causing the feeding tube to become dislodged and leak.There was no reported patient injury.Additional information received 21-nov-2019 stated that some have fallen off with-in days of insertion.The physician notes there have been least three incidences of the bolsters falling off prior to the 2-week.No additional information was provided.

• Brand Name: LAPAROSCOPIC INTRODUCER KIT FOR GASTROSTOMY FEEDING TUBE, 22 FR DILATOR
• Common Device Name: DH EF PERC PLACEMENT PRODUCTS
• Manufacturer (Section D): AVANOS MEDICAL INC.; 5405 windward parkway; alpharetta GA 30004
• MDR Report Key: 9470305
• Report Number: 9611594-2019-00251
• Device Sequence Number: 14503732
• Product Code: KGC
• UDI-Device Identifier: 00350770102375
• UDI-Public: 00350770102375
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K080253
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 12/13/2019

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 Model Number: 10237
• Device Catalogue Number: 10237-04
• 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: 11/18/2019
• Initial Report FDA Received Date: 12/13/2019
• Patient Sequence Number: 1