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 2019-01-25 for STONE CONE M0063903200 390-320 manufactured by Boston Scientific Corporation.
[134084114]
(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 medwatch will be filed.
Patient Sequence No: 1, Text Type: N, H10
[134084115]
It was reported to boston scientific corporation that a stone cone retrieval coil was used during a retrograde intrarenal surgery (rirs) procedure performed in the ureter on (b)(6) 2019. The indication for the procedure was for ureterscopic lithotripsy. According to the complainant, during procedure, when lithotripsy was finished the complainant observed that the length of the stone cone seemed shorter than usual. Another stone cone retrieval coil was used for length comparison and it was discovered that the tip of the stone cone that was used had broken off and was in the ureter of the patient. Tools were used to take out the tip from the patient. There was no serious injury, nor were there any adverse patient effects reported as a result of this event.
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 3005099803-2019-00291 |
| MDR Report Key | 8277406 |
| Report Source | COMPANY REPRESENTATIVE,FOREIG |
| Date Received | 2019-01-25 |
| Date of Report | 2019-03-18 |
| Date of Event | 2019-01-04 |
| Date Mfgr Received | 2019-02-25 |
| Device Manufacturer Date | 2018-06-25 |
| Date Added to Maude | 2019-01-25 |
| 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 | CAROLE MORLEY |
| Manufacturer Street | 300 BOSTON SCIENTIFIC WAY , |
| Manufacturer City | MARLBOROUGH MA 01752 |
| Manufacturer Country | US |
| Manufacturer Postal | 01752 |
| Manufacturer Phone | 5086834015 |
| Manufacturer G1 | LAKE REGION MEDICAL |
| Manufacturer Street | 1525 HERTZ STREET |
| Manufacturer City | CHIHUAHUA |
| Manufacturer Country | MX |
| Single Use | 3 |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | STONE CONE |
| Generic Name | DISLODGER, STONE, FLEXIBLE |
| Product Code | FGO |
| Date Received | 2019-01-25 |
| Returned To Mfg | 2019-02-01 |
| Model Number | M0063903200 |
| Catalog Number | 390-320 |
| Lot Number | 0004346450 |
| Operator | HEALTH PROFESSIONAL |
| Device Availability | R |
| Device Age | DA |
| Device Eval'ed by Mfgr | Y |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | BOSTON SCIENTIFIC CORPORATION |
| Manufacturer Address | 300 BOSTON SCIENTIFIC WAY , MARLBOROUGH MA 01752 US 01752 |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 1. Required No Informationntervention | 2019-01-25 |