MAUDE Adverse Event Report: COVIDIEN CONNECT SFTY SCREW SPIKE NS; PUMP, INFUSION, ENTERAL

Model Number	77000FD
Medical Device Problem Code	Fluid/Blood Leak (1250)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	04/29/2020
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The incident sample has been requested but to date has not been received for evaluation. if the sample is received, or if additional information pertinent to the incident is obtained a follow-up report will be submitted. as part of our manufacturing process, all device history records are reviewed and approved by quality, prior to release of product.
Event or Problem Description
The customer reported that the feeding sets leaked where the tubing apparatus fits into the bag.The patient was duct taping the connection to avoid leaking.
Additional Manufacturer Narrative
Section e1 has been updated to correct the name and complete address of the initial reporter.
Additional Manufacturer Narrative
H 3 evaluation summary: the device history record (dhr) review of the reported lot number shows evidence that the product was released according to all established procedures and quality documentation.One used sample was received at the manufacturing site for evaluation.Visual and functional inspection was performed, and it was found to have a detached cross spike from the line.The root cause and action plan will be documented through formal corrective and preventative action (capa).This complaint will be closed with no further action and will be used for tracking and trending purposes.
Additional Manufacturer Narrative
Update the sample evaluation to reflect that 22 samples were received for evaluation.See below: twenty-two samples were received at the manufacturing site for evaluation.Visual and functional inspections were performed; the cross spike was detached from the line.

• Brand Name: CONNECT SFTY SCREW SPIKE NS
• Common Device Name: PUMP, INFUSION, ENTERAL
• Manufacturer (Section D): COVIDIEN; 15 hampshire street; mansfield MA 02048
• MDR Report Key: 10033964
• Report Number: 1282497-2020-09053
• Device Sequence Number: 14199755
• Product Code: LZH
• UDI-Device Identifier: 10884521190818
• UDI-Public: 10884521190818
• Combination Product (Y/N): N
• Initial Reporter Country: CA
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,consum
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup,Followup,Followup
• Report Date (Section B): 09/02/2020

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
• Operator of Device: No Information
• Device Model Number: 77000FD
• Device Catalogue Number: 77000FD
• Device Lot Number: 192030034
• Was Device Available for Evaluation?: Yes
• Initial Date Received by Manufacturer: 04/29/2020
• Supplement Date Received by Manufacturer: 04/29/2020; 04/29/2020; 04/29/2020
• Initial Report FDA Received Date: 05/07/2020
• Supplement Report FDA Received Date: 05/12/2020; 08/24/2020; 09/02/2020
• Patient Sequence Number: 1