MAUDE Adverse Event Report: MEDLINE INDUSTRIES, LP; TRAY,IRRIGATION,PISTON SYRINGE,60ML,STRL

Model Number DYND20302

Device Problem Material Separation (1562)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Date 01/09/2020

Event Type  malfunction  

Event Description

It was reported that the piston irrigation syringe separated.

Manufacturer Narrative

It was reported that the piston irrigation syringe separated.The separation occurred while pulling back on the syringe.To date, no information has been received to indicate that a user or a patient experienced a death, serious injury, medical intervention, follow-up care, or other adverse health impact associated with the reported problem/issue.A returned sample and a comparative sample from stock were used in the evaluation of the reported problem/issue.Dimensional analysis found that the diameter of the rubber grommet was slightly under the required specification by an average of approximately 0.25mm.A brief functional evaluation was done on the samples by simulating an environment where a great amount of suction was produced on the plunger.It was observed that during these conditions, the grommet would detach from the plunger and remain inside the barrel of the piston irrigation syringe.In an abundance of caution, and in response to an fda 483 issued for cfn 1417592 on 22-jan-2024, this medwatch is being filed.If additional relevant information becomes available a supplemental medwatch will be filed.

• Type of Device: TRAY,IRRIGATION,PISTON SYRINGE,60ML,STRL
• Manufacturer (Section D): MEDLINE INDUSTRIES, LP; three lakes drive; northfield IL 60093 2753
• Manufacturer Contact: nigel vilches ; three lakes drive; northfield, IL 60093-2753
• MDR Report Key: 18825618
• MDR Text Key: 336766919
• Report Number: 1417592-2024-00149
• Device Sequence Number: 1
• Product Code: KYZ
• UDI-Device Identifier: 40080196031802
• UDI-Public: 40080196031802
• Combination Product (y/n): N
• Reporter Country Code: US
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: User Facility
• Reporter Occupation: Other
• Type of Report: Initial
• Report Date: 03/03/2024

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 03/04/2024
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Model Number: DYND20302
• Device Lot Number: 0331907A174
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 01/16/2020
• Date Manufacturer Received: 01/09/2020
• Was Device Evaluated by Manufacturer?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Unknown
• Patient Sequence Number: 1
• Patient Outcome(s): Other