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 2020-01-24 for RUSCH DOUBLE LUMEN BRONCHIAL TUBE SET LEFT 116100-000370 manufactured by Teleflex Medical.
[183754031]
(b)(4).
Patient Sequence No: 1, Text Type: N, H10
[183754032]
Customer complaint reported as: "when unpacking before the operation, the angle connector of the tube is broken off before use. " no patient involvement reported.
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 8040412-2020-00016 |
| MDR Report Key | 9626898 |
| Report Source | COMPANY REPRESENTATIVE,FOREIG |
| Date Received | 2020-01-24 |
| Date of Report | 2020-01-10 |
| Date of Event | 2020-01-01 |
| Date Mfgr Received | 2020-02-28 |
| Date Added to Maude | 2020-01-24 |
| 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 | KATHARINE TARPLEY |
| Manufacturer Street | 3015 CARRINGTON MILL BLVD |
| Manufacturer City | MORRISVILLE NC 27560 |
| Manufacturer Country | US |
| Manufacturer Postal | 27560 |
| Manufacturer Phone | 9194334854 |
| Manufacturer G1 | TELEFLEX MEDICAL SDN. BHD. |
| Manufacturer Street | LOT NO : PT2577 JALEN PERUSAHAAN 4 KAMUNTING INDUSTRIAL ESTATE |
| Manufacturer City | PERAK, WEST MALAYSIA 34600 |
| Manufacturer Country | MY |
| Manufacturer Postal Code | 34600 |
| Single Use | 3 |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | RUSCH DOUBLE LUMEN BRONCHIAL TUBE SET LEFT |
| Generic Name | TUBE, BRONCHIAL (W/WO CONNECT |
| Product Code | BTS |
| Date Received | 2020-01-24 |
| Returned To Mfg | 2020-02-12 |
| Catalog Number | 116100-000370 |
| Lot Number | 19IT37 |
| Device Availability | R |
| Device Age | DA |
| Device Eval'ed by Mfgr | Y |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | TELEFLEX MEDICAL |
| Manufacturer Address | ATHLONE |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 2020-01-24 |