MAUDE Adverse Event Report: C.R. BARD, INC. (COVINGTON) -1018233 BARDEX® ALL-SILICONE FOLEY CATHETER

Model Number 165812

Device Problems Incorrect Measurement (1383); Material Deformation (2976)

Patient Problem Pain (1994)

Event Type  malfunction  

Manufacturer Narrative

The investigation is still in progress.Once the investigation is complete, a supplemental report will be filed.

Event Description

It was reported that when a catheter was removed, a ridge was found at the tip.The nurse felt resistance upon removal.She received assistance from another nurse and was finally able to remove the catheter.During the removal the patient experienced a significant amount of pain.No medical intervention reported.

Manufacturer Narrative

The reported event was confirmed.Visual inspection noted one used two-way foley catheter received.Visual evaluation noted that the balloon was mushroomed upon return.The catheter balloon was inflated with 10 ml methylene blue solution (3 drops 1% aq methylene blue per 100ml distilled water) and balloon concentricity was observed to be 60:40 as compared to attachment 1 of tm0300903 (rev 2).The balloon appeared as if it were about to burst when only 7ml had been injected into the balloon.The balloon rested for 30 minutes without leaks and passively deflated.The balloon had noticeable cuffing and appeared to be severely stretched after deflation.The active length of the catheter balloon was measured (0.4475") and found to be out of specification (0.50" - 0.80").The catheter measured to be 12 fr.Although the reported event was confirmed, a root cause could not be determined.A potential root cause for this failure could be incorrect trimming process.The product was used for treatment purposes.The product was influenced by the reported failure.The product failed to meet specifications.The device history record was reviewed and found nothing that could have caused or contributed to the reported event.The instructions for use were found adequate and state the following: ¿peel to open c.R.Bard, inc.(b)(4).Www.Bardmedical.Com bardex® all-silicone foley catheter catheter shaft made entirely of silicone elastomer pd-50205 11/00 caution: federal (u.S.A.) law restricts this device to sale by or on the order of a physician.Sterile: unless package is opened or damaged.Warning: do not use ointments or lubricants having a petrolatum base.They will damage silicone and may cause balloon to burst.Caution: do not aspirate urine through drainage funnel wall.Storage: store catheters at room temperature away from direct exposure to light, preferably in the original box.Single use only.Do not reuse.Do not resterilize.For urological use only.Valve type: use luer slip syringe.Do not use needle.Recommended inflation capacities 3cc balloon: use 5ml sterile water 5cc balloon: use 10ml sterile water 30cc balloon: use 35ml sterile water do not exceed recommended capacities.Warning: after use, this product may be a potential biohazard.Handle and dispose of in accordance with applicable local, state, and federal laws and regulations.Note: aggressive traction, particularly in the presence of suturing, is not recommended for 100% silicone foley catheters.Bard and bardex are registered trademarks of c.R.Bard, inc.Or an affiliate.To deflate catheter balloon: gently insert a syringe in the catheter valve.Never use more force than is required to make the syringe ¿stick¿ in the valve.If you notice slow or no deflation, re-seat the syringe gently.Allow the balloon to deflate slowly on its own.Do not aspirate or manually accelerate the deflation of the balloon.If permitted by hospital protocol, the valve arm may be severed.If this fails, contact adequately trained professional for assistance, as directed by hospital protocol.Should balloon rupture occur, care should be taken to assure that all balloon fragments have been removed from the patient.Visually inspect the product for any imperfections or surface deterioration prior to use.Released".

Event Description

It was reported that when a catheter was removed, a ridge was found at the tip.The nurse felt resistance upon removal.She received assistance from another nurse and was finally able to remove the catheter.During the removal the patient experienced a significant amount of pain.No medical intervention reported.

• Brand Name: BARDEX® ALL-SILICONE FOLEY CATHETER
• Type of Device: FOLEY CATHETER
• Manufacturer (Section D): C.R. BARD, INC. (COVINGTON) -1018233; 8195 industrial blvd; covington GA 30014
• MDR Report Key: 9337445
• MDR Text Key: 179756755
• Report Number: 1018233-2019-07373
• Device Sequence Number: 1
• Product Code: EZL
• UDI-Device Identifier: 00801741029738
• UDI-Public: (01)00801741029738(10)
• Combination Product (y/n): N
• PMA/PMN Number: K040504
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: other,user facility
• Type of Report: Initial,Followup
• Report Date: 12/10/2019

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 11/18/2019
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: 165812
• Device Catalogue Number: 165812
• Device Lot Number: NGDS1084
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/08/2019
• Date Manufacturer Received: 12/05/2019
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1