MAUDE Adverse Event Report: MEDLINE INDUSTRIES, LP Medline; LUER LOCK ACCESS DEVICE

Model Number	ACSD
Medical Device Problem Codes	Crack (1135); Material Integrity Problem (2978)
Health Effect - Clinical Code	Appropriate Clinical Signs, Symptoms and Conditions Term/Code Not Available (4581)
Date of Event	04/11/2023
Type of Reportable Event	Serious Injury
Event or Problem Description
According to the facility when drawing blood from an iv site the luer portion of the blood tube collection barrel broke creating an open venous flow and subsequent loss of the iv access site.
Additional Manufacturer Narrative
According to the facility when drawing blood from an iv site the luer portion of the blood tube collection barrel broke creating an open venous flow and subsequent loss of the iv access site.Per the facility when this occurs they need to restart the iv.No additional information is available at this time.The sample was returned for evaluation.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.

• Brand Name: Medline
• Common Device Name: LUER LOCK ACCESS DEVICE
• 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: 16902169
• Report Number: 1417592-2023-00208
• Device Sequence Number: 6837493
• Product Code: FMI
• UDI-Device Identifier: 10193489006070
• UDI-Public: 10193489006070
• Combination Product (Y/N): N
• Initial Reporter State: PA
• 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): 05/10/2023

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: ACSD
• Device Catalogue Number: ACSD
• Device Lot Number: 220916
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 04/18/2023
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/11/2023
• Initial Report FDA Received Date: 05/10/2023
• 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