MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed with the FDA on 2018-11-29 for WILLIAMS CYSTOSCOPIC INJECTION NEEDLE 090001 manufactured by Cook Inc.
[128903786]
This mdr is being filed after the associated complaint was reviewed under remediation protocol (b)(4), complaint/mdr retrospective review and remediation and reassessed as reportable. Additional complaint investigation and record remediation was not performed.
Patient Sequence No: 1, Text Type: N, H10
[128903787]
It was reported an issue with cystoscopic injection needle which made the device unusable. It was further noted a longitudinal split on a dilator covered with an unknown substance. In addition, the hub was bent. There was no clinical consequences reported.
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 1820334-2018-03580 |
| MDR Report Key | 8116329 |
| Date Received | 2018-11-29 |
| Date of Report | 2018-11-29 |
| Date of Event | 2016-11-04 |
| Date Mfgr Received | 2018-11-26 |
| Device Manufacturer Date | 2016-02-17 |
| Date Added to Maude | 2018-11-29 |
| 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 |
| Reporter Occupation | OTHER HEALTH CARE PROFESSIONAL |
| Health Professional | 3 |
| Initial Report to FDA | 3 |
| Report to FDA | 3 |
| Event Location | 3 |
| Manufacturer Contact | MR. LARRY POOL |
| Manufacturer Street | 750 DANIELS WAY |
| Manufacturer City | BLOOMINGTON IN 47404 |
| Manufacturer Country | US |
| Manufacturer Postal | 47404 |
| Manufacturer Phone | 8128294891 |
| Manufacturer G1 | COOK INC |
| Manufacturer Street | 750 DANIELS WAY |
| Manufacturer City | BLOOMINGTON IN 47404 |
| Manufacturer Country | US |
| Manufacturer Postal Code | 47404 |
| Single Use | 3 |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 0 |
| Brand Name | WILLIAMS CYSTOSCOPIC INJECTION NEEDLE |
| Generic Name | FBK ENDOSCOPIC INJECTION NEEDLE, GASTROENTEROLOGY-UROLOGY |
| Product Code | FBK |
| Date Received | 2018-11-29 |
| Returned To Mfg | 2016-12-06 |
| Model Number | NA |
| Catalog Number | 090001 |
| Lot Number | 6742775 |
| Device Expiration Date | 2019-02-17 |
| Operator | HEALTH PROFESSIONAL |
| Device Availability | R |
| Device Eval'ed by Mfgr | R |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | COOK INC |
| Manufacturer Address | 750 DANIELS WAY BLOOMINGTON IN 47404 US 47404 |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 2018-11-29 |