MAUDE Adverse Event Report: BECTON DICKINSON MEDICAL SYSTEMS BD BLUNT FILL AND BLUNT FILTER NEEDLE; PISTON SYRINGE

Model Number	305064
Medical Device Problem Code	Material Deformation (2976)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	04/14/2023
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 blunt fill and blunt filter needle the plunger was damaged.There was no report of patient impact.The following information was provided by the initial reporter: did discover that one of the plungers had a visible defect.
Event or Problem Description
It was reported while using bd blunt fill and blunt filter needle the plunger was damaged.There was no report of patient impact.The following information was provided by the initial reporter: did discover that one of the plungers had a visible defect.
Additional Manufacturer Narrative
The following fields were updated due to additional information: d10: device available for eval yes, d10: returned to manufacturer on: 08-jun-2023.H6: investigation summary: one sample and one photo were provided to our quality team for investigation.Through visual inspection, it was observed that the syringe stopper was slightly warped.The photo displayed the stopper was jammed and insecure in assembled syringe.Potential root cause for the jammed/insecure stopper defect is associated with the assembly process.A device history record review showed no rejected inspections or quality issues during the production of the provided batch number that could have contributed to the reported defect.H3 other text : see h10.

• Brand Name: BD BLUNT FILL AND BLUNT FILTER NEEDLE
• Common Device Name: PISTON SYRINGE
• Manufacturer (Section D): BECTON DICKINSON MEDICAL SYSTEMS; route 7 and grace way; canaan CT 06018
• Manufacturer (Section G): BECTON DICKINSON MEDICAL SYSTEMS; route 7 and grace way; canaan CT 06018
• Manufacturer Contact: phillip emmert ; 9450 south state street; sandy, UT 84070 ; 8448235433
• MDR Report Key: 17019899
• Report Number: 1213809-2023-00580
• Device Sequence Number: 7125883
• Product Code: FMF
• UDI-Device Identifier: 30382903050643
• UDI-Public: (01)30382903050643
• Combination Product (Y/N): N
• Initial Reporter Country: CA
• PMA/510(K) Number: K110771
• 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): 06/20/2023

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: 08/31/2026
• Device Model Number: 305064
• Device Catalogue Number: 305064
• Device Lot Number: 1252201
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 05/03/2023
• Supplement Date Received by Manufacturer: 06/20/2023
• Initial Report FDA Received Date: 05/30/2023
• Supplement Report FDA Received Date: 07/06/2023
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 09/09/2021
• 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