MAUDE Adverse Event Report: ARROW INTERNATIONAL LLC ARROW AM PICC 2L 5.5FRX55CM 130CM HYDR NIT SWG; INTRODUCER, CATHETER

Catalog Number	PR-45552-HPHNL
Medical Device Problem Codes	Break (1069); Material Separation (1562)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	05/08/2024
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported "doctor was placing the picc catheter through the peel away sheath.Catheter was successfully in the sheath.Once the doctor went to break the sides of the peel away sheath the plastic wing broke off.The doctor had to grab a clamp to grab the broken sheath body to remove from the patient." there was no patient harm or injury.No medical intervenion required.The patient's current condition is reported as "fine".
Additional Manufacturer Narrative
Qn# (b)(4).
Event or Problem Description
It was reported "doctor was placing the picc catheter through the peel away sheath.Catheter was successfully in the sheath.Once the doctor went to break the sides of the peel away sheath the plastic wing broke off.The doctor had to grab a clamp to grab the broken sheath body to remove from the patient." there was no patient harm or injury.No medical intervenion required.The patient's current condition is reported as "fine".
Additional Manufacturer Narrative
(b)(4).The customer returned one peel-away sheath for evaluation.Signs of use were observed.Visual inspection of the peel-away sheath revealed the peel away sheath extrusion was separated adjacent to the tab.The other tab was intact.The sheath had completely split down the length of the extrusion along the score lines.The sheath body length from the tabs to the distal tip measured 4 1/8"), which is within the specification limits of 3 7/8" - 4 1/8" per peel-away product drawing.The out-er and inner diameter of the sheath could not be measured due to the condition of the returned sample.Functional inspection was not required as part of this complaint investigation.A device history record review was performed, and no relevant findings were identified.The report of a broken peel away sheath tab was confirmed through complaint investigation of the returned sample.Visual analysis revealed that the sheath extrusion had separated directly adjacent to one tab.Based on the customer report and the sample received, manufacturing likely caused or contributed to this event.Non-conformance was initiated to further investigate this complaint issue.Teleflex will continue to monitor and trend for reports of this nature.Corrected data: section d.4.Unique identifier (udi)# corrected from (b)(4) to (b)(4).

• Brand Name: ARROW AM PICC 2L 5.5FRX55CM 130CM HYDR NIT SWG
• Common Device Name: INTRODUCER, CATHETER
• Manufacturer (Section D): ARROW INTERNATIONAL LLC; morrisville NC
• Manufacturer (Section G): ARROW INTERNATIONAL DE MEXICO S.A. DE C.V.; ave. washington 3701; colonia panamericana, chihuahua; chihuahua 31200 ; MX 31200
• Manufacturer Contact: sachin sony ; 3015 carrington mill blvd; morrisville, NC 27560
• MDR Report Key: 19476037
• Report Number: 9680794-2024-00540
• Device Sequence Number: 4071349
• Product Code: DYB
• UDI-Device Identifier: 00801902095770
• UDI-Public: 00801902095770
• Combination Product (Y/N): N
• Initial Reporter State: NJ
• Initial Reporter Country: US
• PMA/510(K) Number: K780532
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: User Facility,Company Representative
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 05/15/2024

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 Expiration Date: 06/30/2025
• Device Catalogue Number: PR-45552-HPHNL
• Device Lot Number: 33F23L0970
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 05/23/2024
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: Not provided
• Supplement Date Received by Manufacturer: 06/10/2024
• Initial Report FDA Received Date: 06/06/2024
• Supplement Report FDA Received Date: 06/21/2024
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 02/04/2024
• 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
• Concomitant Medical Products and Therapy/Usage Dates: NONE REPORTED; NONE REPORTED
• Patient Sex: Unknown