MAUDE Adverse Event Report: BARD ACCESS SYSTEMS STATLOCK IV SELECT MACROBORE 6IN IV START KIT 50 BOX; SET, ADMINISTRATION, INTRAVASCULAR

Model Number	N/A
Medical Device Problem Code	Fluid/Blood Leak (1250)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	05/04/2020
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The device has not been returned to the manufacturer for evaluation.A lot history review (lhr) of judz0180 showed one other similar product complaint(s) from this lot number.The complaints for this lot number (judz0180) have been reported from the same facility.
Event or Problem Description
It was reported iv initiated on (b)(6) 2020, on (b)(6) 2020 the iv j-loop tubing broke from hub.No other information was provided.

• Brand Name: STATLOCK IV SELECT MACROBORE 6IN IV START KIT 50 BOX
• Common Device Name: SET, ADMINISTRATION, INTRAVASCULAR
• Manufacturer (Section D): BARD ACCESS SYSTEMS; 605 n. 5600 w.; salt lake city UT 84116
• MDR Report Key: 10096321
• Report Number: 3006260740-2020-01854
• Device Sequence Number: 19679789
• Product Code: FPA
• UDI-Device Identifier: 00801741082665
• UDI-Public: (01)00801741082665
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K942931
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2020
• Device Explanted Year: 2020
• Reporter Type: Manufacturer
• Report Source: company representative,user f
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 05/28/2020

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: Health Professional
• Device Expiration Date: 03/28/2022
• Device Model Number: N/A
• Device Catalogue Number: IVK0177
• Device Lot Number: JUDZ0180
• Was Device Available for Evaluation?: No
• Event Location: Hospital
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 05/04/2020
• Initial Report FDA Received Date: 05/28/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 84 YR