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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: BAXTER HEALTHCARE CORPORATION POLYFLUX 140H DIALYZER, HIGH PERMEABILITY WITH OR WITHOUT SEALED DIALYSATE SYSTEM

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BAXTER HEALTHCARE CORPORATION POLYFLUX 140H DIALYZER, HIGH PERMEABILITY WITH OR WITHOUT SEALED DIALYSATE SYSTEM Back to Search Results
Catalog Number 112465
Device Problems Break (1069); Fluid/Blood Leak (1250)
Patient Problem No Clinical Signs, Symptoms or Conditions (4582)
Event Date 11/04/2021
Event Type  malfunction  
Event Description
It was reported that during treatment with one (1) unit of polyflux 140h, an external fluid leak due to a break in the header was observed. Blood was returned to the patient. There was no patient injury or medical intervention associated with this event. No additional information is available.
 
Manufacturer Narrative
Phone number: (b)(6). The actual sample and pictures were received for evaluation. A visual inspection of the provided photos showed the product in a package with the product label. The reported condition was not verified. A leakage test of the dialysate side of the actual sample was performed and a leak was observed. The cause was identified as a crack in the welding seam. The reported condition was verified. The cause of the crack is manufacturing related. A batch review was conducted and there were no deviations found related to this reported condition during the manufacture of this lot. A nonconformance has been opened to address this issue. Should additional relevant information become available, a supplemental report will be submitted.
 
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Brand NamePOLYFLUX 140H
Type of DeviceDIALYZER, HIGH PERMEABILITY WITH OR WITHOUT SEALED DIALYSATE SYSTEM
Manufacturer (Section D)
BAXTER HEALTHCARE CORPORATION
deerfield IL
Manufacturer (Section G)
BAXTER HEALTHCARE - HECHINGEN BADEN DIALYZER
holger - crafoord - strasse 26
hechingen D-723 79
GM D-72379
Manufacturer Contact
25212 w. illinois route 120
round lake, IL 
2242702068
MDR Report Key12893363
MDR Text Key288672606
Report Number9611369-2021-00321
Device Sequence Number1
Product Code KDI
UDI-Device Identifier07332414102753
UDI-Public(01)07332414102753
Combination Product (y/n)N
Reporter Country CodeKS
PMA/PMN Number
NA
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type Foreign,Health Professional,Company Representative
Reporter Occupation
Type of Report Initial
Report Date 11/30/2021
1 Device was Involved in the Event
0 Patients were Involved in the Event:
Date FDA Received11/30/2021
Is this an Adverse Event Report? No
Is this a Product Problem Report? Yes
Device Operator
Device Catalogue Number112465
Device Lot Number1-5813-H-01
Was Device Available for Evaluation? Device Returned to Manufacturer
Date Returned to Manufacturer11/23/2021
Is the Reporter a Health Professional? Yes
Date Manufacturer Received11/04/2021
Was Device Evaluated by Manufacturer? Device Not Returned to Manufacturer
Is the Device Single Use? Yes
Is This a Reprocessed and Reused Single-Use Device? No
Type of Device Usage Initial

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