MAUDE Adverse Event Report: MMJ SA DE CV (USD) SHILEY; TUBE TRACHEOSTOMY AND TUBE CUFF

Model Number	6.0PDL
Medical Device Problem Code	Physical Resistance/Sticking (4012)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	12/03/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
If information is provided in the future, a supplemental report will be issued.
Event or Problem Description
According to the reporter, the device's obturator did not slide correctly in.There was no allegation of patient death or serious in jury.
Additional Manufacturer Narrative
Additional information: d10, e1(initial reporter and facility information), g4, h3, h6 h3 evaluation summary: one sample was received for evaluation and lot number provided was received as well.A visual test was performed and it was observed all the components are assembled properly at the tube.The product met specification as received.A functional test was performed according to process instruction.The received obturator was impregnated with alcohol and inserted into the cannula and no obstruction or difficulties were detected during the test, neither ridges were observed in the inner diameter of the cannula.Information has been added to the database and trends will continue to be monitored.If information is provided in the future, a supplemental report will be issued.

• Brand Name: SHILEY
• Common Device Name: TUBE TRACHEOSTOMY AND TUBE CUFF
• Manufacturer (Section D): MMJ SA DE CV (USD); ave henequen no 1181 desarroll; ciudad juarez,mx 32590 ; MX 32590
• MDR Report Key: 9500358
• Report Number: 2936999-2019-01045
• Device Sequence Number: 1305061
• Product Code: JOH
• UDI-Device Identifier: 10884522030083
• UDI-Public: 10884522030083
• Combination Product (Y/N): N
• Initial Reporter State: OH
• Initial Reporter Country: US
• PMA/510(K) Number: K955680
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,distri
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 05/01/2020

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: 12/15/2021
• Device Model Number: 6.0PDL
• Device Catalogue Number: 6.0PDL
• Device Lot Number: 16L0451JZX
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 04/14/2020
• Initial Date Received by Manufacturer: 12/06/2019
• Supplement Date Received by Manufacturer: 04/16/2020
• Initial Report FDA Received Date: 12/20/2019
• Supplement Report FDA Received Date: 05/01/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1