MAUDE Adverse Event Report: VYARIE MEDICAL VITAL SIGNS; ADULT ANESTHESIA BREATHING CIRCUIT

Model Number	A5V560X4
Medical Device Problem Code	Disconnection (1171)
Health Effect - Clinical Code	Insufficient Information (4580)
Date of Event	09/20/2024
Type of Reportable Event	Malfunction
Event or Problem Description
Fda user facility mw report mw 0500470000-2024-0039 reported, the circuit separated at the joint multiple times during the case, had to intervene.The circuit disconnected multiple times at the y connection during the case.Caused interruption of the procedure and interfered with the anesthesia patient care.There was no reported injury.
Additional Manufacturer Narrative
The device history record for lot 0004284395 was reviewed and the product was produced according to product specifications.The sample was reported to be available but has not yet been received by the manufacturer; without a sample to perform functional evaluation the root cause cannot be determined.All information reasonably known as of 30 oct 2024 has been included in this health authority report.Should additional information be obtained, a follow-up health authority report will be provided.The information provided by sun med holdings llc.Represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to sun med holdings llc.Sun med holdings llc.Has no independent knowledge of the event reported but is relaying the information that was provided by the user facility where the incident occurred.This product incident is documented in the sun med holdings complaint database and identified as complaint (b)(4).This information is submitted pursuant to 21cfr803, in compliance with the medical device reporting requirement and should not be considered to be an admission that an sun med holdings llc.Product is defective or caused serious injury.
Additional Manufacturer Narrative
Correction: h10.The device history record for lot 0004284395 was reviewed and the product was produced according to product specifications.The sample was reported to be available but has not yet been received by the manufacturer; without a sample to perform functional evaluation the root cause cannot be determined.All information reasonably known as of 26 nov 2024 has been included in this health authority report.Should additional information be obtained, a follow-up health authority report will be provided.The information provided by sun med holdings llc.Represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to sun med holdings llc.Sun med holdings llc.Has no independent knowledge of the event reported but is relaying the information that was provided by the user facility where the incident occurred.This product incident is documented in the sun med holdings complaint database and identified as complaint (b)(4).This information is submitted pursuant to 21cfr803, in compliance with the medical device reporting requirement and should not be considered to be an admission that an sun med holdings llc.Product is defective or caused serious injury.
Event or Problem Description
Fda user facility mw report mw (b)(4) reported, the circuit separated at the joint multiple times during the case, had to intervene.The circuit disconnected multiple times at the y connection during the case.Caused interruption of the procedure and interfered with the anesthesia patient care.There was no reported injury.

• Brand Name: VITAL SIGNS
• Common Device Name: ADULT ANESTHESIA BREATHING CIRCUIT
• Manufacturer (Section D): VYARIE MEDICAL; productos urologos de mexico s; no. 85 parque indus. mexicali; mexicali baja california, mexico ; MX
• Manufacturer (Section G): VYARIE MEDICAL; productos urologos de mexico s; no. 85 parque indus. mexicali; mexicali baja california, ; MX
• Manufacturer Contact: racheal cooper ; 2710 north ridge dr nw; ste a; grand rapids, MI 49544 ; 2054826767
• MDR Report Key: 20570960
• Report Number: 8030673-2024-01025
• Device Sequence Number: 15615843
• Product Code: OFP
• UDI-Device Identifier: 10190752120242
• UDI-Public: (01)10190752120242(10)0004284395(11)240513(17)270125
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: EXEMPT
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Other,Health Professional,User Facility,Company Representative
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 11/26/2024

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 Model Number: A5V560X4
• Device Catalogue Number: A5V560X4
• Device Lot Number: 0004284395
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 10/02/2024
• Supplement Date Received by Manufacturer: 10/28/2024
• Initial Report FDA Received Date: 10/30/2024
• Supplement Report FDA Received Date: 11/26/2024
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 05/13/2024
• 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: Unknown
• Patient Sequence Number: 1
• Patient Age: 22 YR
• Patient Sex: Prefer Not To Disclose
• Patient Weight: 44 KG
• Patient Race: Black Or African American