MAUDE Adverse Event Report: BAXTER HEALTHCARE CORPORATION AC PUMP POWER CORD CSA GREY; SYSTEM/DEVICE, PHARMACY COMPOUNDING

Catalog Number 400100678

Device Problem Defective Component (2292)

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

Event Date 07/08/2021

Event Type  malfunction  

Manufacturer Narrative

The device was not returned and the serial number is unknown; therefore, a device analysis could not be completed.Should additional relevant information become available, a supplemental report will be submitted.

Event Description

It was reported that the power cord was observed frayed and the wires were exposed.There was no patient involvement.No additional information is available.

Manufacturer Narrative

Correction made to d1: brand name: replacement, main module (previously submitted as ac pump power cord csa grey) correction made to d4: catalogue #: 2400mr (previously submitted as 400100678) correction made to d4: serial no.: (b)(6) (previously submitted as ni) should additional relevant information become available, a supplemental report will be submitted.

• Brand Name: AC PUMP POWER CORD CSA GREY
• Type of Device: SYSTEM/DEVICE, PHARMACY COMPOUNDING
• Manufacturer (Section D): BAXTER HEALTHCARE CORPORATION; deerfield IL
• Manufacturer (Section G): BAXTER HEALTHCARE - ENGLEWOOD; 14445 grasslands dr; englewood CO 80112
• Manufacturer Contact: 25212 w. illinois route 120; round lake, IL ; 2242702068
• MDR Report Key: 12268103
• MDR Text Key: 264779882
• Report Number: 1416980-2021-04744
• Device Sequence Number: 1
• Product Code: NEP
• Combination Product (y/n): Y
• Reporter Country Code: US
• PMA/PMN Number: NA
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,health
• Reporter Occupation: Pharmacist
• Type of Report: Initial
• Report Date: 08/03/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 08/03/2021
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Catalogue Number: 400100678
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 07/08/2021
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Unknown
• Patient Sequence Number: 1