MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a company representative,foreig report with the FDA on 2017-12-22 for STONE CONE NITINOL UROLOGICAL RETRIEVAL COIL M0063903200 390-320 manufactured by Boston Scientific - Marlborough.
[95695953]
(b)(4). Lake region medical- (b)(4). The device has not been received for analysis. Upon receipt and completion of the failure analysis of the complaint device, if there is any further relevant information from that review, a supplemental mdr will be filed.
Patient Sequence No: 1, Text Type: N, H10
[95695954]
It was reported to boston scientific corporation that a stone cone nitinol urological retrieval coil was used in the kidney, during a ureteroscopy with lithotripsy procedure. The procedure was performed on (b)(6) 2017. According to the complainant, during the procedure when the device was removed from the patient, it was noticed that the device was fragmented. Another ureteroscopy was performed and a piece of the blue plastic cover was observed inside the patient. The procedure was completed using another different device. There is no confirmation if the piece of the blue plastic cover was retrieved. There were no patient complications reported as a result of this event. The patient's condition at the conclusion of the procedure was reported to be? Stable?.
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 3005099803-2017-03820 |
| MDR Report Key | 7144235 |
| Report Source | COMPANY REPRESENTATIVE,FOREIG |
| Date Received | 2017-12-22 |
| Date of Report | 2017-12-06 |
| Date of Event | 2017-11-29 |
| Date Mfgr Received | 2018-01-25 |
| Device Manufacturer Date | 2017-07-28 |
| Date Added to Maude | 2017-12-22 |
| 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 | EMP. NANCY CUTINO |
| Manufacturer Street | 100 BOSTON SCIENTIFIC WAY |
| Manufacturer City | MARLBOROUGH MA 01752 |
| Manufacturer Country | US |
| Manufacturer Postal | 01752 |
| Manufacturer Phone | 5086834000 |
| Single Use | 3 |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | STONE CONE NITINOL UROLOGICAL RETRIEVAL COIL |
| Generic Name | DISLODGER, STONE, FLEXIBLE |
| Product Code | FGO |
| Date Received | 2017-12-22 |
| Returned To Mfg | 2017-12-27 |
| Model Number | M0063903200 |
| Catalog Number | 390-320 |
| Lot Number | 0003768063 |
| Operator | PHYSICIAN |
| Device Availability | R |
| Device Age | DA |
| Device Eval'ed by Mfgr | Y |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | BOSTON SCIENTIFIC - MARLBOROUGH |
| Manufacturer Address | 100 BOSTON SCIENTIFIC WAY MARLBOROUGH MA 01752 US 01752 |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 1. Required No Informationntervention | 2017-12-22 |