MAUDE Adverse Event Report: C.R. BARD, INC. (BASD) -3006260740 DOT PROV 4F DL MAX 3CG; CATHETER,INTRAVASCULAR,THERAPEUTIC,LONG-TERM GREATER THAN 30 DAYS

Model Number	N/A
Medical Device Problem Code	Material Frayed (1262)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	07/25/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The manufacturer has received the sample and will evaluate.Results are expected soon.A lot history review (lhr) of refs1619 showed no other similar product complaint(s) from this lot number.
Event or Problem Description
It was reported "stylet wire broke off during picc insertion." additional information received 08/03/2021: left insertion which met slight resistance (repositioned patient) easy insert to distal svc.Picc measurement off, picc pulled to retrim, noticed copper tip protruding from end of picc at which time noticed that tip was broken off.Wire was not taped to hold position and was noted to have moved from original position.Did the wire get stuck in the patient: no.Placement info: left basilic 4 fr.2 lumen.Was there patient harm reported?: no harm.
Additional Manufacturer Narrative
H11: section a through f - the information provided by bd represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to bd.The following were reviewed as part of this investigation: patient severity, complaint and lot history review, applicable previous investigation(s), sample (if available), labeling, applicable manufacture records, and applicable fmea documents.Based on a review of this information, the following was concluded: the complaint of a damaged stylet is confirmed; however, the exact cause is unknown.One 3cg stylet was returned for evaluation.An initial visual observation showed use residue on the returned sample.The returned stylet was observed to be broken into two pieces approximately 5 cm proximal to its distal tip.The epoxy tip of the stylet was observed present and intact on the distal segment.The core wire of the stylet was observed to be protruding from the proximal break site.Multiple bends and kinks were observed in the stylet.A microscopic observation revealed the break sites in the polyimide tubing were uneven with a rough surface texture and plastic deformation.The break site of the core wire of the stylet was observed to be tapered and angled slightly.Multiple kinks were observed in the polyimide tubing between magnet interfaces leading up to the break sites.The observed fracture features were indicative of severe and/or repetitive stylet kinking, which likely occurred during the insertion process.However, the exact circumstances providing for that type of event were ultimately unknown.
Event or Problem Description
It was reported "stylet wire broke off during picc insertion." additional information received on 08/03/2021: left insertion which met slight resistance (repositioned patient) easy insert to distal svc.Picc measurement off, picc pulled to retrim - noticed copper tip protruding from end of picc at which time noticed that tip was broken off.Wire was not taped to hold position and was noted to have moved from original position.Did the wire get stuck in the patient: no.Placement info: left basilic 4 fr.2 lumen.Was there patient harm reported?: no harm.

• Brand Name: DOT PROV 4F DL MAX 3CG
• Common Device Name: CATHETER,INTRAVASCULAR,THERAPEUTIC,LONG-TERM GREATER THAN 30 DAYS
• Manufacturer (Section D): C.R. BARD, INC. (BASD) -3006260740; 605 north 5600 west; salt lake city 84116
• MDR Report Key: 12351067
• Report Number: 3006260740-2021-03437
• Device Sequence Number: 3549338
• Product Code: LJS
• UDI-Device Identifier: 00801741130366
• UDI-Public: (01)00801741130366
• Combination Product (Y/N): N
• Initial Reporter State: AZ
• Initial Reporter Country: US
• PMA/510(K) Number: K162443
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,other
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 09/24/2021

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: Health Professional
• Device Model Number: N/A
• Device Catalogue Number: S1274108D
• Device Lot Number: REFS1619
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 08/18/2021
• Initial Date Received by Manufacturer: 07/25/2021
• Supplement Date Received by Manufacturer: 09/24/2021
• Initial Report FDA Received Date: 08/20/2021
• Supplement Report FDA Received Date: 09/29/2021
• 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
• Patient Age: 27 YR
• Patient Weight: 65