MAUDE Adverse Event Report: LAKE REGION MEDICAL CPS COURIER

Catalog Number	DS2G002
Medical Device Problem Code	Difficult to Advance (2920)
Health Effect - Clinical Code	Insufficient Information (4580)
Date of Event	02/20/2025
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Complaint investigation underway and will be attached to this report.
Event or Problem Description
While implantation the courier guidwire medium was damaged.A peace of the tip was stuck in the vein.Luckily we could move this out.
Event or Problem Description
While implantation the courier guidwire medium was damaged.A peace of the tip was stuck in the vein.Luckily we could move this out.
Additional Manufacturer Narrative
Complaint investigation is completed.

• Brand Name: CPS COURIER
• Common Device Name: CPS COURIER
• Manufacturer (Section D): LAKE REGION MEDICAL; parkmore west business park; galway, H91 C K22; EI H91 CK22
• Manufacturer (Section G): LAKE REGION MEDICAL; parkmore west business park; galway, H91 C K22; EI H91 CK22
• Manufacturer Contact: jaseem saqib ; parkmore west business park; galway, H91 C-K22 ; EI H91 CK22
• MDR Report Key: 21544645
• Report Number: 3006010712-2025-00013
• Device Sequence Number: 15466539
• Product Code: DQX
• UDI-Device Identifier: 15414734505168
• UDI-Public: (01)15414734505168(17)270831(10)9158346
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K073082
• 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: Administrator/Supervisor
• Remedial Action: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 04/02/2025

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 Catalogue Number: DS2G002
• Device Lot Number: 9158346
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 02/26/2025
• Supplement Date Received by Manufacturer: 02/26/2025
• Initial Report FDA Received Date: 03/07/2025
• Supplement Report FDA Received Date: 04/02/2025
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 09/13/2024
• 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: Initial
• Patient Sequence Number: 1
• Patient Sex: Unknown