MAUDE Adverse Event Report: JIANGSU CAINA MEDICAL CO., LTD. MEDLINE; SAFETY NEEDLE

Catalog Number	CA255
Medical Device Problem Code	Insufficient Device Problem Information (3190)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Type of Reportable Event	Malfunction
Event or Problem Description
The customer reported that safety needle detached from syringe.
Additional Manufacturer Narrative
The returned samples was requested but hasn't been received till now, the lot number of this event was received, the dhr of this lot was reviewed without any issuses.The retained samples of the lot was tested and the samples met the specification.The root cause can't detected currrently, no action will be taken currently, a supplemental report will be submitted if further information received.

• Brand Name: MEDLINE
• Common Device Name: SAFETY NEEDLE
• Manufacturer (Section D): JIANGSU CAINA MEDICAL CO., LTD.; no 23, huanxi rd; zhutang town; jiangyin, jiangsu 21441 5; CH 214415
• Manufacturer (Section G): JIANGSU CAINA MEDICAL CO., LTD.; no 23, huanxi rd; zhutang town; jiangyin, jiangsu 21441 5; CH 214415
• Manufacturer Contact: camel zhou ; no 23, huanxi rd; zhutang town; jiangyin, jiangsu 21441-5 ; CH 214415
• MDR Report Key: 19102864
• Report Number: 3005670221-2024-00043
• Device Sequence Number: 7268513
• Product Code: FMF
• UDI-Device Identifier: 06971564465021
• UDI-Public: (01)06971564465021
• Combination Product (Y/N): N
• PMA/510(K) Number: K193526
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Distributor
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 04/14/2024

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 Expiration Date: 12/31/2025
• Device Catalogue Number: CA255
• Device Lot Number: 89721010001
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 12/23/2023
• Initial Report FDA Received Date: 04/14/2024
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 01/01/2021
• 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: Unknown
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other
• Patient Sex: Unknown