MAUDE Adverse Event Report: COVIDIEN K 924 500 ML FEEDING BAG; PUMP, INFUSION

Model Number	772025
Medical Device Problem Code	Air/Gas in Device (4062)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	11/23/2020
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
Customer reported air bubbles in the line while using the feeding bag.

• Brand Name: K 924 500 ML FEEDING BAG
• Common Device Name: PUMP, INFUSION
• Manufacturer (Section D): COVIDIEN; 15 hampshire street; mansfield MA 02048
• MDR Report Key: 11571804
• Report Number: 1282497-2021-10004
• Device Sequence Number: 4150856
• Product Code: FRN
• UDI-Device Identifier: 10884521000759
• UDI-Public: 10884521000759
• 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
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 03/25/2021

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: No Information
• Device Model Number: 772025
• Device Catalogue Number: 772025
• Device Lot Number: 201950101
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 11/23/2020
• Initial Report FDA Received Date: 03/25/2021
• Patient Sequence Number: 1