MAUDE Adverse Event Report: CAREFUSION SD ALARIS SYSTEM; PUMP, INFUSION

Model Number	8110
Medical Device Problem Codes	Break (1069); Physical Resistance/Sticking (4012)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	12/08/2022
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
A device history record review is performed on each device reported in a mdr reportable event along with other methods of investigation of this mdr report.Per 803.52(f)(11)(iii) the information provided was obtained from servicing activities performed on the device.There were no additional details obtainable or provided at the time of service.See manufacturer narrative.
Event or Problem Description
It was reported that a failure was observed during a planned preventative maintenance, recall remediation, or repair order service event.[[service type]];[plunger issue].There was no reported patient involvement.
Additional Manufacturer Narrative
Correction: describe event or problem annex b: b21 annex c: c21 annex d: d16 additional information: annex a: a0509 annex b: b01 annex c: c02 annex d: d15.Annex g: g03012.
Event or Problem Description
It was reported that a failure was observed during a planned preventative maintenance, recall remediation, or repair order service event.[depot repair];[plunger issue].There was no reported patient involvement.

• Brand Name: ALARIS SYSTEM
• Common Device Name: PUMP, INFUSION
• Manufacturer (Section D): CAREFUSION SD; 10020 pacific mesa blvd; san diego CA 92121 4386
• Manufacturer Contact: brett wilko ; 10020 pacific mesa blvd; san diego, CA 92121-4386 ; 8586172000
• MDR Report Key: 16076937
• Report Number: 2016493-2022-245009
• Device Sequence Number: 6295101
• Product Code: FRN
• UDI-Device Identifier: 10885403423208
• UDI-Public: (01)10885403423208
• Combination Product (Y/N): N
• Initial Reporter Country: BC
• PMA/510(K) Number: K133532
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Other,Foreign
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 02/03/2023

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: 8110
• Device Catalogue Number: 8110 ALARIS SYRINGE MODULE
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 12/08/2022
• Supplement Date Received by Manufacturer: 12/08/2022
• Initial Report FDA Received Date: 12/30/2022
• Supplement Report FDA Received Date: 02/08/2023
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 10/30/2009
• Is the Device Labeled for Single Use? (Y/N): No
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Unknown
• Patient Sequence Number: 1
• Patient Sex: Unknown