MAUDE Adverse Event Report: TERUMO BCT RIKA PLASMA DONATION SYSTEM

Catalog Number	21300
Medical Device Problem Codes	No Apparent Adverse Event (3189); Insufficient Device Problem Information (3190)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	12/16/2023
Type of Reportable Event	Malfunction
Event or Problem Description
The customer reported to terumo bct customer support that a leak was discovered at the disconnect on a rika device because the black top was not properly sealed onto the bottle.The customer stated that the bottle was not properly sealed to the lid, therefore resulting in a contaminated return.The patient id is unknown at this time.Per the customer this was listed as an uncommon donation event was opened at center level.The collection set is not available for return because it was discarded by the customer.
Additional Manufacturer Narrative
Investigation is in process, a follow-up report will be provided.
Additional Manufacturer Narrative
Further evaluation of this event has determined that the device did not cause or contribute to a death or serious injury, nor is there a likely potential for death or serious injury associated with this event based on additional investigational information.Rika is not human transfusable product and this event does not represent a reportable event.No further reporting will be provided as this does not represent a reportable event.
Event or Problem Description
The customer reported to terumo bct customer support that a leak was discovered at the disconnect on arika device because the black top was not properly sealed onto the bottle.The customer stated that the bottle was not properly sealed to the lid, therefore resulting in a contaminated return.The patient id is unknown at this time.Per the customer this was listed as an uncommon donation event was opened at center level.The collection set is not available for return because it was discarded by the customer.

• Brand Name: RIKA PLASMA DONATION SYSTEM
• Common Device Name: RIKA PLASMA DONATION SYSTEM
• Manufacturer (Section D): TERUMO BCT; lakewood CO 80215
• Manufacturer (Section G): TERUMO BCT; 10810 w. collins ave; lakewood CO 80215
• Manufacturer Contact: scot hilden ; 10810 w. collins ave; lakewood, CO 80215
• MDR Report Key: 18476338
• Report Number: 1722028-2024-00012
• Device Sequence Number: 6794357
• Product Code: GKT
• UDI-Device Identifier: 05020583213005
• UDI-Public: 05020583213005
• Combination Product (Y/N): N
• Initial Reporter State: CO
• Initial Reporter Country: US
• PMA/510(K) Number: BK210635
• 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: Administrator/Supervisor
• Type of Report: Initial,Followup
• Report Date (Section B): 01/09/2024

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: Health Professional
• Device Catalogue Number: 21300
• Device Lot Number: 2301251001
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 12/15/2023
• Supplement Date Received by Manufacturer: 01/24/2024
• Initial Report FDA Received Date: 01/09/2024
• Supplement Report FDA Received Date: 01/26/2024
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 01/25/2023
• 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
• Outcome Attributed to Adverse Event: Other
• Patient Age: 43 YR
• Patient Sex: Female