MAUDE Adverse Event Report: SISTEMAS MEDICOS ALARIS, S.A. DE C.V. BD MAXGUARD ADMINISTRATION SET WITH NEEDLELESS Y-SITE(S); INTRAVASCULAR ADMINISTRATION SET

Model Number	MX9433
Medical Device Problem Code	Leak/Splash (1354)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	03/08/2023
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
A device evaluation and/or device history review is anticipated but is not complete.Upon completion, a supplemental report will be filed.
Event or Problem Description
It was reported while using bd maxguard administration set with needleless y-site(s) components separated and leakage occurred.There was no report of patient impact.The following information was provided by the initial reporter: "we are having another report on item 32011614 set admin iv 130in 15drop 4port 50/ca being defective.One of our facilities is reporting an issue/concern with an item that it is purchased from your company.Situation: issue: primed the iv tubing.Primed normally.Did the iv.When i connected the iv and opened the fluid line, the fluid and blood starting going everywhere due to the medication port not attached.".
Additional Manufacturer Narrative
H6: investigation summary no product or photo was returned by the customer.It was reported by customer that "primed the iv tubing.Primed normally the iv.When they connected the iv and opened the fluid line, the fluid and blood starting going everywhere due to the medication port not attached".However it could not be verified due to the product not being returned for failure investigation.A device history record review for model mx9433 and lot number 22129074 was performed.There were no quality notifications issued for the failure mode reported by the customer during the production build of this set of lot.Due to no sample being received, an investigation could not be performed, and a root cause could not be determined.
Event or Problem Description
It was reported while using bd maxguard administration set with needleless y-site(s) components separated and leakage occurred.There was no report of patient impact.The following information was provided by the initial reporter: "we are having another report on item 32011614 set admin iv 130in 15drop 4port 50/ca being defective.One of our facilities is reporting an issue/concern with an item that it is purchased from your company.Situation: issue: primed the iv tubing.Primed normally.Did the iv.When i connected the iv and opened the fluid line, the fluid and blood starting going everywhere due to the medication port not attached.".

• Brand Name: BD MAXGUARD ADMINISTRATION SET WITH NEEDLELESS Y-SITE(S)
• 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 ; 8448235433
• MDR Report Key: 16624709
• Report Number: 9616066-2023-00573
• Device Sequence Number: 17710217
• Product Code: FPA
• UDI-Device Identifier: 50885403237780
• UDI-Public: (01)50885403237780
• Combination Product (Y/N): N
• Initial Reporter State: UT
• Initial Reporter Country: US
• PMA/510(K) Number: K051499
• 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): 04/10/2023

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 Expiration Date: 12/06/2025
• Device Model Number: MX9433
• Device Catalogue Number: MX9433
• Device Lot Number: 22129074
• 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: 03/08/2023
• Supplement Date Received by Manufacturer: 04/10/2023
• Initial Report FDA Received Date: 03/27/2023
• Supplement Report FDA Received Date: 04/16/2023
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Date Device Manufactured: 12/04/2022
• 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