COOK SILICONE BALLOON HYSTEROSALPINGOGRAPHY INJECTION CATHETER G17870 J-CHSG-703000

MAUDE Adverse Event Report

MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a distributor,foreign,other,use report with the FDA on 2019-08-12 for COOK SILICONE BALLOON HYSTEROSALPINGOGRAPHY INJECTION CATHETER G17870 J-CHSG-703000 manufactured by Cook Inc.

MAUDE Entry Details

• Report Number: 1820334-2019-01981
• MDR Report Key: 8883390
• Report Source: DISTRIBUTOR,FOREIGN,OTHER,USE
• Date Received: 2019-08-12
• Date of Report: 2019-08-29
• Date Mfgr Received: 2019-08-28
• Device Manufacturer Date: 2019-01-09
• Date Added to Maude: 2019-08-12
• 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: MR. LARRY POOL
• Manufacturer Street: 750 DANIELS WAY
• Manufacturer City: BLOOMINGTON IN 47404
• Manufacturer Country: US
• Manufacturer Postal: 47404
• Manufacturer Phone: 8123392235
• 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: 3

Device Details

• Brand Name: COOK SILICONE BALLOON HYSTEROSALPINGOGRAPHY INJECTION CATHETER
• Generic Name: HES INSUFFLATOR-CARBON DIOXIDE, URETOTUBAL (AND ACCESSORIES)
• Product Code: HES
• Date Received: 2019-08-12
• Model Number: G17870
• Catalog Number: J-CHSG-703000
• Lot Number: 9432727
• Operator: HEALTH PROFESSIONAL
• Device Availability: N
• Device Age: DA
• 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

Patients

Patient Number	Treatment	Outcome	Date
1	0		2019-08-12