MAUDE Adverse Event Report: BARD PERIPHERAL VASCULAR, INC. BIOPSY MISSION KIT; BIOPSY INSTRUMENT

Model Number	2010MS
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Hematoma (1884); Hemoptysis (1887); Hemorrhage/Blood Loss/Bleeding (1888); Pain (1994)
Date of Event	10/13/2020
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
As the lot number for the device was not provided, a review of the device history records could not be performed.The sample was not returned to the manufacturer for inspection/evaluation.Therefore, the investigation of the reported event is inconclusive.Based upon the available information, the definitive root cause for this event is unknown.The instructions for use (ifu) is adequate for the reported device/patient code(s) and provides general instructions for use, as well as warnings, precautions and potential complications associated with the device.Upon receipt of new or additional information, a follow-up report will be submitted as applicable.
Event or Problem Description
It was reported through a (b)(6) clinical follow-up survey on core biopsy instruments, there were 2 occurrences of hematoma, 2 occurrences of hemorrhage, and 2 occurrences of pain during kidney biopsy procedure(s).It was further reported there was 1 occurrence of hemoptysis requiring hospitalization or specific therapy, 2 occurrences of pain, and 2 occurrences of thoracostomy tube placement requiring prolonged admission, catheter exchange or pleurodesis during lung biopsy procedure(s).There current status of the patient(s) was not provided.

• Brand Name: BIOPSY MISSION KIT
• Common Device Name: BIOPSY INSTRUMENT
• Manufacturer (Section D): BARD PERIPHERAL VASCULAR, INC.; 1625 w 3rd st.; tempe AZ 85281
• MDR Report Key: 10808124
• Report Number: 2020394-2020-20386
• Device Sequence Number: 17051416
• Product Code: KNW
• UDI-Device Identifier: 00801741097027
• UDI-Public: (01)00801741097027
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K133948
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 10/28/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Model Number: 2010MS
• Device Catalogue Number: 2010MS
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 10/13/2020
• Initial Report FDA Received Date: 11/09/2020
• 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