MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a foreign,health professional,o report with the FDA on 2019-12-13 for WAYNE PNEUMOTHORAX SET N/A C-UTPT-1020-WAYNE manufactured by Cook Inc.
[179414636]
(b)(6). Pma/510(k) #: exempt. (b)(4). This report includes information known at this time. A follow up report will be submitted should additional relevant information become available.
Patient Sequence No: 1, Text Type: N, H10
[179414637]
It was reported that the shaft of a wayne pneumothorax catheter separated when a patient extracted it from their body. The patient became "excited" and extracted the catheter from themselves. The part of the device outside the body was torn off when the patient extracted it. It was reported that nothing was connected to the catheter at the time of the event. A section of the device did not remain inside the patient. The patient required replacement of the catheter. No other adverse effects have been reported for this incident.
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 1820334-2019-03110 |
| MDR Report Key | 9467091 |
| Report Source | FOREIGN,HEALTH PROFESSIONAL,O |
| Date Received | 2019-12-13 |
| Date of Report | 2020-03-03 |
| Date of Event | 2019-10-13 |
| Date Mfgr Received | 2020-02-25 |
| Device Manufacturer Date | 2019-08-07 |
| Date Added to Maude | 2019-12-13 |
| 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. JENNIFER CANADA |
| 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 |
| Brand Name | WAYNE PNEUMOTHORAX SET |
| Generic Name | JOL CATHETER AND TIP, SUCTION |
| Product Code | JOL |
| Date Received | 2019-12-13 |
| Model Number | N/A |
| Catalog Number | C-UTPT-1020-WAYNE |
| Lot Number | 9788381 |
| Operator | LAY USER/PATIENT |
| Device Availability | N |
| Device Age | DA |
| Device Eval'ed by Mfgr | Y |
| 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 | 1. Required No Informationntervention | 2019-12-13 |