MAUDE Adverse Event Report: MEDLINE INDUSTRIES, LP; LHK AUGUSTA HEALTH CARE

Catalog Number	VASC1446
Medical Device Problem Code	Connection Problem (2900)
Health Effect - Clinical Code	Insufficient Information (4580)
Date of Event	01/16/2024
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
According to the customer, "it really does seem to be a mixture of pre-procedure and middle of the procedure occurrences of the same issue happening where the syringe will not stay on the manifold without physically being held in place".There is no further information.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.In an abundance of caution, and in response to an fda 483 issued for cfn 1417592 on 22-jan-2024, this medwatch is being filed for the reported problem/issue.If additional relevant information becomes available a supplemental medwatch will be filed.
Event or Problem Description
According to the customer, "it really does seem to be a mixture of pre-procedure and middle of the procedure occurrences of the same issue happening where the syringe will not stay on the manifold without physically being held in place".
Additional Manufacturer Narrative
Update to b3, d9, h3, and h6: after further investigation, it was determined that the date of the event was 01/16/2024.A sample was returned to and evaluated by the manufacturer on 03/08/2024.The investigation included trend analysis, testing of the actual/suspected device, and a review of production records.The investigation identified a mechanical issue in which the syringes backed off/rolled free of the manifold connection, thereby replicating the reported defect.A cause remains unestablished.If any additional relevant information is identified or obtained, a supplemental medwatch will be submitted.

• Common Device Name: LHK AUGUSTA HEALTH CARE
• Manufacturer (Section D): MEDLINE INDUSTRIES, LP; three lakes dr; northfield IL 60093 2753
• Manufacturer Contact: gavin-ainsley nadong ; three lakes dr; northfield, IL 60093-2753 ; 2249317042
• MDR Report Key: 19125515
• Report Number: 1417592-2024-00517
• Device Sequence Number: 12824099
• Product Code: OES
• UDI-Device Identifier: 40195327473182
• UDI-Public: 40195327473182
• Combination Product (Y/N): N
• Initial Reporter State: VA
• 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,Followup
• Report Date (Section B): 03/02/2026

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 Catalogue Number: VASC1446
• Device Lot Number: 23JBV645
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 01/23/2024
• Supplement Date Received by Manufacturer: 02/05/2026
• Initial Report FDA Received Date: 04/17/2024
• Supplement Report FDA Received Date: 03/02/2026
• 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
• Patient Sex: Unknown