MAUDE Adverse Event Report: MEDLINE INDUSTRIES, LP Medline; TL1LYR 14FR10ML LATEX DB SAFES

Model Number	URO170114Q
Medical Device Problem Code	Leak/Splash (1354)
Health Effect - Clinical Code	Appropriate Clinical Signs, Symptoms and Conditions Term/Code Not Available (4581)
Date of Event	03/09/2023
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
According to the facility on (b)(6) 2023 the sample port was leaking and fell off requiring the facility to replace the foley catheter.Per the facility the bed was soiled with urine and the staff member replaced the foley catheter with no issues or harm to the patient.No additional information is available at this time.The sample was returned and the customer complaint was confirmed, however, a definitive root cause could not be determined at this time.It has been determined that the reported event could cause or contribute to serious injury if it were to occur.In an abundance of caution, this medwatch is being filed.If any further relevant information is identified or obtained, a supplemental medwatch will be submitted.
Event or Problem Description
According to the facility on (b)(6) 2023 the sample port was leaking and fell off requiring the facility to replace the foley catheter.

• Brand Name: Medline
• Common Device Name: TL1LYR 14FR10ML LATEX DB SAFES
• Manufacturer (Section D): MEDLINE INDUSTRIES, LP; three lakes drive; northfield IL 60093
• Manufacturer Contact: justin herrmann ; three lakes drive; northfield, IL 60093
• MDR Report Key: 16645003
• Report Number: 1417592-2023-00146
• Device Sequence Number: 5516593
• Product Code: OHR
• UDI-Device Identifier: 10193489442120
• UDI-Public: 10193489442120
• Combination Product (Y/N): N
• Initial Reporter State: VA
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 03/30/2023

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Model Number: URO170114Q
• Device Catalogue Number: URO170114Q
• Device Lot Number: 9692111000
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 03/17/2023
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/10/2023
• Initial Report FDA Received Date: 03/30/2023
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• 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
• Outcome Attributed to Adverse Event: Other
• Patient Sex: Unknown