MAUDE Adverse Event Report: MEDLINE INDUSTRIES, LP; CAM CYSTOSCOPY PACK

Model Number	DYNJ37627B
Medical Device Problem Codes	Fluid/Blood Leak (1250); Mechanical Problem (1384); Suction Problem (2170)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	10/21/2020
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that a toomey syringe component did not "draw up properly," the plunger got "stuck," and that it is "dripping once full of fluid.".
Additional Manufacturer Narrative
It was reported that a toomey syringe component did not "draw up properly," the plunger got "stuck," and that it is "dripping once full of fluid." according to the reporting facility, "it seems as though there is an issue with the pressure into the syringe." no serious injury or adverse impact to a patient or a user was originally reported.To date, no information has been received to indicate that a user or a patient experienced a death, serious injury, medical intervention, follow-up care, or other adverse health impact associated with the reported problem/issue.A photo was provided for review.Inspection of the photo was unable to confirm the reported problem/issue.No physical sample was returned for evaluation.The reported problem/issue was unable to be reproduced or confirmed and no root cause was determined.In an abundance of caution, and in response to an fda 483 issued for cfn 1417592 on (b)(6) 2024, this medwatch is being filed for the reported problem/issue.If additional relevant information becomes available a supplemental medwatch will be filed.

• Common Device Name: CAM CYSTOSCOPY PACK
• Manufacturer (Section D): MEDLINE INDUSTRIES, LP; three lakes drive; northfield IL 60093 2753
• Manufacturer Contact: nigel vilches ; three lakes drive; northfield, IL 60093-2753
• MDR Report Key: 18976248
• Report Number: 1423395-2024-00186
• Device Sequence Number: 15126897
• Product Code: LRO
• UDI-Device Identifier: 40889942028529
• UDI-Public: 40889942028529
• 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: User Facility
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 03/25/2024

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
• Device Model Number: DYNJ37627B
• Device Lot Number: 20GBB390
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 10/21/2020
• Initial Report FDA Received Date: 03/25/2024
• Was Device Evaluated by Manufacturer? (Y/N): No
• 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