MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a distributor,foreign report with the FDA on 2016-07-11 for NON-REBREATHER OXYGEN MASK, ADULT 108MM manufactured by Unomedical Sa De Cv.
[49237641]
Based on the available information, this event is deemed to be a reportable malfunction. No patient harm was reported. Additional details have been requested but not provided to date. Should additional information become available, a follow-up report will be submitted. (b)(4). Note: a total of (b)(4) cases are associated with this complaint. A separate fda form 3500a has been completed for that case.
Patient Sequence No: 1, Text Type: N, H10
[49237642]
Complaint received from a distributor reporting that "the tube break off from the mask. This occurs the oxygen de-saturation for the patient. " the issue was noted at the fixation between the mask and the tube. Photos were received depicting the reported product complaint.
Patient Sequence No: 1, Text Type: D, B5
[63554396]
A preliminary evaluation of the reported cases were reviewed collectively due to similar failure modes reported for tubing disconnecting from mask. These complaints included a review of complaints reported between october 27, 2014 to october 27, 2016 (2 year period) for this failure. Additionally, the last product monitoring reviews (pmrs) were also reviewed and no trends were identified. This issue will be monitored through the post market product monitoring review process. No additional patient/event details have been provided to date. Should additional information become available, a follow-up report will be submitted. Reported to the fda on december 27, 2016.
Patient Sequence No: 1, Text Type: N, H10
| Report Number | 9680866-2016-00080 |
| MDR Report Key | 5783840 |
| Report Source | DISTRIBUTOR,FOREIGN |
| Date Received | 2016-07-11 |
| Date of Report | 2016-06-07 |
| Date Mfgr Received | 2017-02-21 |
| Date Added to Maude | 2016-07-11 |
| Event Key | 0 |
| Report Source Code | Manufacturer report |
| Manufacturer Link | Y |
| Number of Patients in Event | 0 |
| Adverse Event Flag | 3 |
| Product Problem Flag | 3 |
| Reprocessed and Reused Flag | 3 |
| Health Professional | 3 |
| Initial Report to FDA | 3 |
| Report to FDA | 3 |
| Event Location | 3 |
| Manufacturer Contact | MRS. JEANETTE JOHNSON |
| Manufacturer Street | 7900 TRIAD CENTER DRIVE SUITE 400 |
| Manufacturer City | GREENSBORO NC 27409 |
| Manufacturer Country | US |
| Manufacturer Postal | 27409 |
| Manufacturer Phone | 3365424681 |
| Single Use | 3 |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | NON-REBREATHER OXYGEN MASK, ADULT |
| Generic Name | MASK, OXYGEN, NON-REBREATHING |
| Product Code | KGB |
| Date Received | 2016-07-11 |
| Model Number | 108MM |
| Lot Number | 110558 |
| Operator | HEALTH PROFESSIONAL |
| Device Availability | N |
| Device Age | DA |
| Device Eval'ed by Mfgr | R |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | UNOMEDICAL SA DE CV |
| Manufacturer Address | AV. INDUSTRIAL FALCON LOTE 7 PARQUE IND DEL NORTE REYNOSA, TAMAULIPAS 88736 MX 88736 |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 2016-07-11 |