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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: SISTEMAS MEDICOS ALARIS S.A. DE C.V. BD ALARIS PUMP MODULE SMARTSITE LOW SORBING INFUSION SET; INTRAVASCULAR ADMINISTRATION SET

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SISTEMAS MEDICOS ALARIS S.A. DE C.V. BD ALARIS PUMP MODULE SMARTSITE LOW SORBING INFUSION SET; INTRAVASCULAR ADMINISTRATION SET Back to Search Results
Catalog Number 11532269
Device Problem Leak/Splash (1354)
Patient Problem Hypersensitivity/Allergic reaction (1907)
Event Date 01/26/2024
Event Type  malfunction  
Manufacturer Narrative
H.3.If a device evaluation and/or device history review is completed, a supplemental report will be filed.
 
Event Description
It was reported that bd alaris pump module smartsite low sorbing infusion set had flow issues and leaking the following information was received by the initial reporter with the following verbatim: we had another incident where iv tubing was leaking.We have removed the tubing and want to send to the manufacturer.Could you please advise on the process.We had a defective set (see below).The ref # is (b)(4).The lot # is (10)23150138.Please let us know wat you need from us.Additional information received any adverse event or serious injury reported to patient or healthcare professional? 2 events of bd lot # (10)23150138 large infusion tubing leaking one patient had a picc line that clotted off and required removal and subsequent iv placement second patient: the rn noted drops of iv fluid dripping onto the floor.The tubing was immediately changed out.No known harm to the patient was there a delay of, or change in, the course of treatment due to the event? yes, see above, neonatal picc become clotted and required removal and subsequent iv placement any sample or photo available for investigation? yes see attached how was the patient outcome? are there any clinical signs, health consequences or impact? patient required a septic workup due to risk of infection how was treatment completed for customer? i¿m not sure what this question is asking patient status? multiple new peripheral ivs have been required.Family decline new picc line after the last one required removal any picture of this complaint see attached re: one of the tubing that was leaking 8.Please explain elaborate issue? a.Filter was noted to be wet ~0600 after tubing was changed the evening prior (approximately 9 hour prior).9.Date of event? 1/26/24 and 1/29/24.10.Physical available/not available? yes both tubings are available.12.Customer address? (b)(6).
 
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Brand Name
BD ALARIS PUMP MODULE SMARTSITE LOW SORBING INFUSION SET
Type of Device
INTRAVASCULAR ADMINISTRATION SET
Manufacturer (Section D)
SISTEMAS MEDICOS ALARIS S.A. DE C.V.
blvd. insurgentes no. 20351
parque industrial el florido
tijuana
Manufacturer (Section G)
SISTEMAS MEDICOS ALARIS S.A. DE C.V.
blvd. insurgentes no. 20351
parque industrial el florido
tijuana
Manufacturer Contact
helen cox (mdr)
75 north fairway drive
vernon hills, IL 60061
8473935694
MDR Report Key18775657
MDR Text Key337293481
Report Number9616066-2024-00289
Device Sequence Number1
Product Code FPA
Combination Product (y/n)N
Reporter Country CodeUS
PMA/PMN Number
K944320
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type User Facility
Reporter Occupation Other Health Care Professional
Type of Report Initial
Report Date 02/22/2024
1 Device was Involved in the Event
1 Patient was Involved in the Event
Date FDA Received02/26/2024
Is this an Adverse Event Report? No
Is this a Product Problem Report? Yes
Device Operator Other
Device Catalogue Number11532269
Device Lot NumberUNKNOWN
Is the Reporter a Health Professional? Yes
Date Manufacturer Received01/30/2024
Was Device Evaluated by Manufacturer? Device Not Returned to Manufacturer
Is the Device Single Use? Yes
Type of Device Usage Initial
Patient Sequence Number1
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