MAUDE Adverse Event Report: SISTEMAS MEDICOS ALARIS, S.A. DE C.V. BD MAXPLUS¿ PRESSURE RATED EXTENSION SET; INTRAVASCULAR ADMINISTRATION SET

Catalog Number	MP5313-C
Medical Device Problem Code	Complete Blockage (1094)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	10/20/2022
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
A device evaluation is anticipated but has not yet begun.Upon completion of the investigation, a supplemental report will be filed.
Event or Problem Description
It was reported that the bd maxplus¿ pressure rated extension set was blocked during the priming process.The following information was provided by the initial reporter: ¿each set is being inspected and flushed for patency prior to use on patient.Rn hooked saline flush up to extension set to prime for patient use.Rn was unable to prime fluid through extension set and replaced with a different extension set that primed without difficulty.On further inspection, the defective extension set was hooked to an empty syringe and with moderate pressure applied ejected a piece of what appeared to be clear plastic.Later in the day another rn experienced the same issue with the same product.".
Additional Manufacturer Narrative
No product or photo was returned by the customer.The customer complaint of flow issues- fluid blockage - complete occlusion could not be verified due to the product not being returned for failure investigation.A device history record review for mp5313-c lot number 22089254 was performed.There were no quality notifications issued for the failure mode reported by the customer during the production build of this set.Due to no sample being received, an investigation could not be performed and a root cause could not be determined.H3 other text : see h10.
Event or Problem Description
It was reported that the bd maxplus¿ pressure rated extension set was blocked during the priming process.The following information was provided by the initial reporter: ¿each set is being inspected and flushed for patency prior to use on patient.Rn hooked saline flush up to extension set to prime for patient use.Rn was unable to prime fluid through extension set and replaced with a different extension set that primed without difficulty.On further inspection, the defective extension set was hooked to an empty syringe and with moderate pressure applied ejected a piece of what appeared to be clear plastic.Later in the day another rn experienced the same issue with the same product".

• Brand Name: BD MAXPLUS¿ PRESSURE RATED EXTENSION SET
• Common Device Name: INTRAVASCULAR ADMINISTRATION SET
• Manufacturer (Section D): SISTEMAS MEDICOS ALARIS, S.A. DE C.V.; blvd. insurgentes no. 20351; parque industrial el florido; tijuana
• Manufacturer (Section G): SISTEMAS MEDICOS ALARIS, S.A. DE C.V.; blvd. insurgentes no. 20351; parque industrial el florido; tijuana
• Manufacturer Contact: phillip emmert ; 9450 south state street; sandy, UT 84070 ; 8015296192
• MDR Report Key: 15791394
• Report Number: 8041187-2022-00662
• Device Sequence Number: 5616261
• Product Code: FPA
• UDI-Device Identifier: 10885403236716
• UDI-Public: (01)10885403236716
• Combination Product (Y/N): N
• Initial Reporter State: NC
• Initial Reporter Country: US
• PMA/510(K) Number: NA
• 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): 12/19/2022

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 Expiration Date: 08/12/2025
• Device Catalogue Number: MP5313-C
• Device Lot Number: 22089254
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 10/20/2022
• Supplement Date Received by Manufacturer: 12/19/2022
• Initial Report FDA Received Date: 11/14/2022
• Supplement Report FDA Received Date: 01/05/2023
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 08/09/2022
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Patient Sex: Unknown