MAUDE Adverse Event Report: SISTEMAS MEDICOS ALARIS, S.A. DE C.V. EXT SET W/VLV PORT & LL; INTRAVASCULAR ADMINISTRATION SET

Model Number	30204E
Medical Device Problem Code	Leak/Splash (1354)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	02/23/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Investigation summary: no product or photo was returned by the customer.The customer complaint that right at the tip it is completely separated from where it is supposed to be sealed and blood is leaking from the tip could not be verified due to the product not being returned for failure investigation.A device history record review for model 30204e lot number 20119642 was performed.The search showed that a total of (b)(4) units in 1 lot number was built on 25nov2020.There were no quality notifications issued for the failure mode reported by the customer during the production build of this set.Due to no sample being received, an investigation could not be performed and a root cause could not be determined.This incident has been added to our database of reported incidents.Our business team regularly reviews the collected data for identification of emerging trends.
Event or Problem Description
It was reported that the ext set w/vlv port & ll separated at the tip connected to the patients catheter and leaked blood.The following information was provided by the initial reporter: "we had an issue with one of our extension sets, used for stem cell collection, and right at the tip it is completely separated from where it is supposed to be sealed and blood is leaking from the tip of it.It¿s coming from the end that screws onto the patient¿s catheter.".

• Brand Name: EXT SET W/VLV PORT & LL
• Common Device Name: INTRAVASCULAR ADMINISTRATION SET
• Manufacturer (Section D): SISTEMAS MEDICOS ALARIS, S.A. DE C.V.; blvd. insurgentes no. 20351; parque industrial el florido; tijuana
• MDR Report Key: 11529964
• Report Number: 9616066-2021-50514
• Device Sequence Number: 12054506
• Product Code: FPA
• UDI-Device Identifier: 50885403235175
• UDI-Public: 50885403235175
• Combination Product (Y/N): N
• Initial Reporter State: MO
• Initial Reporter Country: US
• PMA/510(K) Number: K960280
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: other,user facility
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 03/04/2021

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: Other
• Device Expiration Date: 11/25/2023
• Device Model Number: 30204E
• Device Catalogue Number: 30204E
• Device Lot Number: 20119642
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/23/2021
• Initial Report FDA Received Date: 03/19/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1