MAUDE Adverse Event Report: BECTON DICKINSON KIT TABLET; INTELLIPORT SYSTEM

Model Number	516704
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	04/15/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The manufacturing location for this product is pride industries.This site is an oem manufacturing site.Therefore, bd corporate headquarters in (b)(4) has been listed and the (b)(4) fda registration number has been used for the manufacture report number.Medical device expiration date: na.A device evaluation and/or device history review is anticipated, but is not complete.Upon completion, a supplemental report will be filed.
Event or Problem Description
It was reported that kit tablet screen went blank.The following information was provided by the initial reporter: material no.516704, batch no.20028t02.It is reported customer witnessed screen go blank.Verbiage received, - "from complaint section in an intelliport phase iii survey: date: (b)(6) 2021 , case (b)(4) , cart-1."screen went black during case.Could not resolve on my own.Tablet fully charged.Needed assistance from study coordinator".
Additional Manufacturer Narrative
H.6.Investigation: no photos or samples were received by our quality team for evaluation.A device history record review found no non-conformances associated with this issue during production of this batch.Upon review of the logs of this cart, there were no findings with the tablet application as the application did not crash.The windows application and system event logs also did not show any findings.The tablet may have been put to sleep.
Event or Problem Description
It was reported that kit tablet screen went blank.The following information was provided by the initial reporter: material no.516704, batch, no.20028t02.It is reported customer witnessed screen go blank.Verbiage received, - "from complaint section in an intelliport phase iii survey: date: (b)(6) 2021, case 219, cart-1."screen went black during case.Could not resolve on my own.Tablet fully charged.Needed assistance from study coordinator".

• Brand Name: KIT TABLET
• Common Device Name: INTELLIPORT SYSTEM
• Manufacturer (Section D): BECTON DICKINSON; 1 becton drive; franklin lakes NJ 07417
• MDR Report Key: 11829549
• Report Number: 2243072-2021-01482
• Device Sequence Number: 14563781
• Product Code: PHC
• UDI-Device Identifier: 00382905167041
• UDI-Public: 00382905167041
• Combination Product (Y/N): N
• Initial Reporter State: PA
• Initial Reporter Country: US
• PMA/510(K) Number: K182092
• 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,Followup
• Report Date (Section B): 06/17/2021

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 Model Number: 516704
• Device Catalogue Number: 516704
• Device Lot Number: 20028T02
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 04/15/2021
• Supplement Date Received by Manufacturer: 06/17/2021
• Initial Report FDA Received Date: 05/14/2021
• Supplement Report FDA Received Date: 07/02/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1