MAUDE Adverse Event Report: C.R. BARD, INC. (BASD) -3006260740 MINILOC SAFETY INFUSION SET 20G X 1 IN WITH Y-SITE; SET, ADMINISTRATION, INTRAVASCULAR

Model Number	N/A
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	09/16/2020
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The manufacturer has received the sample and will evaluate.Results are expected soon.A lot history review (lhr) of aserf029 showed no other similar product complaint(s) from this lot number.
Event or Problem Description
It was reported a patient came to the unit with a cracked y-site on a 1¿ huber needle which caused leaking.Additional info.Received 09/23/2020: "what type of catheter securement was utilized? tegaderm"."was there patient harm reported?: yes, chemotherapy leaked onto patient¿s skin".
Additional Manufacturer Narrative
H11: section a through f - the information provided by bd represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to bd.The following were reviewed as part of this investigation: patient severity, trend analysis, applicable previous investigation(s), sample (if available), and applicable fmea documents.Based on a review of this information, the following was concluded: the complaint of a cracked y-site was confirmed and the cause was supplier-related.The product returned for evaluation was one 20ga x 1¿ miniloc safety infusion set.Usage residues were observed throughout the sample and the safety mechanism was engaged.A longitudinally aligned split was observed in the y-site.Microscopic inspection of the split revealed a granular fracture surface.Discoloration and abundant superficial stress cracking were observed in the vicinity of the split.The split propagated along a molding weld line.The split propagated along a molding feature, indicating that features created during the molding process caused the observed fracturing.The stress fracturing observed further suggested that some part of the manufacturing process affected the mechanical properties of the y-site material.The device is a supplied component and the supplier has been notified of this event.
Event or Problem Description
It was reported a patient came to the unit with a cracked y-site on a 1¿ huber needle which caused leaking.Additional info.Received 09/23/2020: "what type of catheter securement was utilized? tegaderm"."was there patient harm reported?: yes, chemotherapy leaked onto patient¿s skin".

• Brand Name: MINILOC SAFETY INFUSION SET 20G X 1 IN WITH Y-SITE
• Common Device Name: SET, ADMINISTRATION, INTRAVASCULAR
• Manufacturer (Section D): C.R. BARD, INC. (BASD) -3006260740; 605 north 5600 west; salt lake city 84116
• MDR Report Key: 10663054
• Report Number: 3006260740-2020-20042
• Device Sequence Number: 2949742
• Product Code: FPA
• UDI-Device Identifier: 00801741048029
• UDI-Public: (01)00801741048029
• Combination Product (Y/N): N
• Initial Reporter State: NJ
• Initial Reporter Country: US
• PMA/510(K) Number: K050600
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,other
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 11/30/2020

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 Model Number: N/A
• Device Catalogue Number: 0682010
• Device Lot Number: ASERF029
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 09/21/2020
• Initial Date Received by Manufacturer: 09/16/2020
• Supplement Date Received by Manufacturer: 11/30/2020
• Initial Report FDA Received Date: 10/12/2020
• Supplement Report FDA Received Date: 12/21/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other