MAUDE Adverse Event Report: ICU MEDICAL DE MEXICO, S. DE R.L. DE C.V. 17" EXT SET W/0.2 MICRON FILTER, MICROCLAVE CLEAR, CLAMP, ROTATING LUER; STOPCOCK, I.V. SET

Model Number MC9079

Device Problem Infusion or Flow Problem (2964)

Patient Problem No Consequences Or Impact To Patient (2199)

Event Date 10/01/2020

Event Type  malfunction  

Manufacturer Narrative

No sample was returned.Without the return of the sample a comprehensive failure investigation cannot be performed, and a cause cannot be determined.A device history review for lot# 4915987, relevant commodities were reviewed, and no non-conformances were found that would have contributed to the reported complaint.Additional reporter information: (b)(6): due to system limitations, date returned to mfg is populated with 10/26/2020, however no device was returned.

Event Description

User facility medwatch report was received and stated the following: air bubbles present between filter and patient.I was changing hal (hyperalimentation) and il (intravenous) lines infusing through a picc line.I had primed the tubing, checked for and dispelled air bubbles in the line.Once the line was attached to the patient, air bubbles developed between the filter and the patient.The infusion was immediately stopped, a new filter was primed and reattached to the patient.Again air bubbles appeared in the same area of the line.Another rn then primed a whole new line, no further air bubbles noted.The remaining stock of filters of that lot number were pulled for testing.The original intended procedure was iv infusion.The problem that the user have was device failure (e.G.Broke, couldn¿t get it to work or stopped working).There was patient involvement but no harm reported.This report is for the second of two devices.

• Brand Name: 17" EXT SET W/0.2 MICRON FILTER, MICROCLAVE CLEAR, CLAMP, ROTATING LUER
• Type of Device: STOPCOCK, I.V. SET
• Manufacturer (Section D): ICU MEDICAL DE MEXICO, S. DE R.L. DE C.V.; avenida cuarzo no. 250; ensenada, b.cfa. 22790 ; MX 22790
• Manufacturer Contact: michael visocnik ; 600 n. field dr.; lake forest, IL 60045 ; 2247062300
• MDR Report Key: 10777104
• MDR Text Key: 214420769
• Report Number: 9617594-2020-00471
• Device Sequence Number: 1
• Product Code: FMG
• UDI-Device Identifier: 00887709078161
• UDI-Public: (01)00887709078161(17)250601(10)4915987
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K964435
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,health
• Reporter Occupation: Nurse
• Type of Report: Initial
• Report Date: 10/06/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: MC9079
• Device Catalogue Number: MC9079
• Device Lot Number: 4915987
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 10/26/2020
• Is the Reporter a Health Professional?: Yes
• Initial Date Manufacturer Received: 10/06/2020
• Initial Date FDA Received: 11/03/2020
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 06/01/2020
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Treatment: HYPERALIMENTATION, UNK MFG; PICC LINE
• Patient Age: 2 MO