MAUDE Adverse Event Report: MEDLINE INDUSTRIES, LP; BLOCK TRAY

Catalog Number	DYNJRA1212
Medical Device Problem Code	Appropriate Device Problem Term/Code Not Available (3191)
Health Effect - Clinical Code	Foreign Body In Patient (2687)
Date of Event	10/13/2023
Type of Reportable Event	Serious Injury
Event or Problem Description
According to the facility on 10/13/23 "during spinal procedure local lidocaine infiltrated into the skin with 25g needle, after withdrawing the syringe it was noticed that the needle broke off inside the patient and into the skin".
Additional Manufacturer Narrative
According to the facility on 10/13/23 "during spinal procedure local lidocaine infiltrated into the skin with 25g needle, after withdrawing the syringe it was noticed that the needle broke off inside the patient and into the skin".Per the facility "attempts to remove by anesthesia and surgery unsuccessful".No additional information is available.The sample was requested 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.

• Common Device Name: BLOCK 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: 18266404
• Report Number: 1417592-2023-00483
• Device Sequence Number: 7890722
• Product Code: LRO
• UDI-Device Identifier: 10888277789838
• UDI-Public: 10888277789838
• Combination Product (Y/N): N
• Initial Reporter State: MA
• 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): 12/05/2023

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 Catalogue Number: DYNJRA1212
• Device Lot Number: 23FDA875
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/13/2023
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 11/07/2023
• Initial Report FDA Received Date: 12/05/2023
• 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