MAUDE Adverse Event Report: BD MEDICAL (BD WEST) MEDICAL SURGICAL BD PRECISIONGLIDE NEEDLE; HYPODERMIC SINGLE LUMEN NEEDLE

Model Number	305111
Medical Device Problem Code	Complete Blockage (1094)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	06/02/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Investigation summary: bd implemented a thorough investigation following our corrective preventative action protocol via capa# (b)(4).This was opened for a trend in reports of ¿needle clogged / blocked¿.The issue is temporary interruption of flow of insulin into the reservoir.Based on the investigation, this issue appears to be related to the use case which involves drawing insulin from a vial into a syringe and then filling the reservoir of the insulin pump via a small port off the body in an iterative process, utilizing existing / ¿off the shelf¿ products rather than a product designed for this use.Bd products are designed to be single use, and because this is an "off the shelf" product, bd specifications do not take into account any requirements specific to the tandem use case.The investigation concludes the complaints are related to the use case and not due to a product nonconformance.
Event or Problem Description
It was reported that the bd precisionglide¿ needle was blocked and wouldn't allow insulin to flow through.The following information was provided by the initial reporter: "caller reported that insulin would not go through the needle".

• Brand Name: BD PRECISIONGLIDE NEEDLE
• Common Device Name: HYPODERMIC SINGLE LUMEN NEEDLE
• Manufacturer (Section D): BD MEDICAL (BD WEST) MEDICAL SURGICAL; 1852 10th avenue; columbus NE 68601
• MDR Report Key: 12297880
• Report Number: 1911916-2021-00799
• Device Sequence Number: 3807512
• Product Code: FMI
• UDI-Device Identifier: 30382903051114
• UDI-Public: 30382903051114
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: K021475
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: distributor,other
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 07/30/2021

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: Lay User/Patient
• Device Model Number: 305111
• Device Catalogue Number: 305111
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 07/12/2021
• Initial Report FDA Received Date: 08/09/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 70 YR