MAUDE Adverse Event Report: BAXTER HEALTHCARE CORPORATION EXACTAMIX; SET, I.V. FLUID TRANSFER

Model Number	H938751
Medical Device Problem Code	Device Contamination with Chemical or Other Material (2944)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	07/31/2024
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Should additional relevant information become available, a supplemental report will be submitted.
Event or Problem Description
It was reported that thirteen (13) micro-volume inlets had particulate matter (pm).The pm was further described as a dark/brown/black spots or fiber; the location of the pm was on the white connectors, spike, or pouches.This was observed prior to use.There was no patient involvement.No additional information is available.
Additional Manufacturer Narrative
H4: the lot was manufactured between march 13, 2023 - march 14, 2023.H11: h11: thirteen actual devices and photographs of the samples were provided for evaluation.The returned photographs were reviewed, and it was noted that small spots of particles were observed in the sealed packaging of the products pictured.A visual inspection was performed on the actual samples, and it was noted that sample #1 had a dark spot on the white inlet connector, and a pink fiber in package weld seal, sample #2 had a dark spot or fiber particle on the spike housing, sample #3 had a dark spot particulate on the spike housing, sample #4, #5, and #6 had a dark spot particulate on the white connector, sample #7 had slight excess silicone on the spike, sample # 8 had a dark spot or fiber on the white connector, sample #9 had spots and fiber on the spike housing, sample #10 had dark fiber on the white connector, sample #11 had dark spot particulates on the white connector, sample #12 had dark spot particulate on the white connector, and sample #13 had dark fiber under the spike cap.The reported condition was verified.The cause of the condition could not be determined; however, the cause was possibly related to manufacturing or the packaging process.A batch review was conducted and there were no deviations found related to this reported condition during the manufacture of this lot.Should additional relevant information become available, a supplemental report will be submitted.

• Brand Name: EXACTAMIX
• Common Device Name: SET, I.V. FLUID TRANSFER
• Manufacturer (Section D): BAXTER HEALTHCARE CORPORATION; deerfield IL
• Manufacturer (Section G): AVAILMED; c. industrial lt. 001 mz. 105; no 20905 int a, col cd ind.; tijuana, baja california 22444 ; MX 22444
• Manufacturer Contact: 25212 w. illinois route 120; round lake, IL 60073 ; 2242702068
• MDR Report Key: 20136096
• Report Number: 1416980-2024-04718
• Device Sequence Number: 7203423
• Product Code: LHI
• UDI-Device Identifier: 00085412477299
• UDI-Public: (01)00085412477299(10)60444792(17)260228
• Combination Product (Y/N): N
• Initial Reporter Country: HK
• PMA/510(K) Number: K903159
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,Company Representative
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 11/19/2024

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: Other
• Device Expiration Date: 02/28/2026
• Device Model Number: H938751
• Device Catalogue Number: H938751
• Device Lot Number: 60444792
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 08/08/2024
• Supplement Date Received by Manufacturer: 10/23/2024
• Initial Report FDA Received Date: 09/04/2024
• Supplement Report FDA Received Date: 11/19/2024
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• 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
• Patient Sex: Unknown