MAUDE Adverse Event Report: MEDLINE INDUSTRIES, LP MEDLINE; TTL1LYR 14FR10ML 100%SIL TMP TRAY

Model Number	URO170814T
Medical Device Problem Code	Material Integrity Problem (2978)
Health Effect - Clinical Code	Appropriate Clinical Signs, Symptoms and Conditions Term/Code Not Available (4581)
Date of Event	03/06/2023
Type of Reportable Event	Serious Injury
Event or Problem Description
According to the facility (b)(6) 2023 the sample port detached and "the rn removed the foley with the detached sample port and inserted a new foley catheter".
Additional Manufacturer Narrative
According to the facility (b)(6) 2023 the sample port detached and "the rn removed the foley with the detached sample port and inserted a new foley catheter".Per the facility the patient was not harmed when this occurred.No additional information is available at this time.The sample has not been returned for evaluation 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.
Additional Manufacturer Narrative
Device was returned for evaluation and root cause was determined to be compenent defect.

• Brand Name: MEDLINE
• Common Device Name: TTL1LYR 14FR10ML 100%SIL TMP TRAY
• 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: 16664876
• Report Number: 1417592-2023-00149
• Device Sequence Number: 20487228
• Product Code: OHR
• UDI-Device Identifier: 10888277868335
• UDI-Public: 10888277868335
• Combination Product (Y/N): N
• Initial Reporter State: AL
• 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,Followup
• Report Date (Section B): 04/05/2023

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: URO170814T
• Device Catalogue Number: URO170814T
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/15/2023
• Supplement Date Received by Manufacturer: 04/05/2023
• Initial Report FDA Received Date: 04/03/2023
• Supplement Report FDA Received Date: 04/05/2023
• 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