MAUDE Adverse Event Report: MEDLINE INDUSTRIES, LP; DBD-PICC LINE INSERTION PACK

Model Number	DYNJ66654A
Medical Device Problem Codes	Crack (1135); Material Twisted/Bent (2981)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	11/01/2023
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that a syringe component was found to be broken within the pack.
Additional Manufacturer Narrative
It was reported that a syringe component was found to be broken within the pack.No serious injury or adverse impact to a procedure, patient, or 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 and the reported problem/issue was confirmed.In the photo, the syringe plunger was observed to be bent and cracked.No physical sample was returned for evaluation.A definitive root cause was unable to be determined.In an abundance of caution, and in response to an fda 483 issued for (b)(4) 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: DBD-PICC LINE INSERTION 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: 19060397
• Report Number: 1423395-2024-00339
• Device Sequence Number: 14917785
• Product Code: OFF
• UDI-Device Identifier: 40195327001026
• UDI-Public: 40195327001026
• Combination Product (Y/N): N
• Initial Reporter State: IL
• 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): 04/08/2024

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: DYNJ66654A
• Device Lot Number: 23DMH174
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 11/01/2023
• Initial Report FDA Received Date: 04/08/2024
• 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
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other
• Patient Sex: Unknown