MAUDE Adverse Event Report: SMITHS MEDICAL ASD, INC. PORTEX ABG-LINE DRAW 3ML; TUBES, VIALS, SYSTEMS, SERUM SEPARATORS, BLOOD COLLECTION

Catalog Number	G1470J
Medical Device Problem Code	Disconnection (1171)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	01/01/2025
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Investigation including root cause analysis is in progress.A supplemental mdr will be filed as necessary in accordance with 21 cfr 803.56 when additional reportable information becomes available.
Event or Problem Description
It was reported that the cap did not close, and it came off quickly.According to the user facility, there were no infectious disease reported due to the result of the event.There were no patient harm or adverse events reported.
Additional Manufacturer Narrative
Visual inspection did not reveal any defects or anomalies.To evaluate the reported issue of a loose connection, the syringe and filter-pro device was tested according to combo leak test qtm\022-00-00.Results: separation of the components was observed.When pressure was applied, the filter-pro "popped off" and became disconnected from the syringe.In this respect, the returned syringe samples and filter-pro devices did not function as intended.The complaint was confirmed as stated.The syringes are purchased pre-siliconized.Complaint information will continue to be monitored for any new information or adverse trends and further actions will be taken accordingly.
Event or Problem Description
It was reported that the cap did not close, and it came off quickly.According to the user facility, there were no infectious disease reported due to the result of the event.There were no patient harm or adverse events reported.

• Brand Name: PORTEX ABG-LINE DRAW 3ML
• Common Device Name: TUBES, VIALS, SYSTEMS, SERUM SEPARATORS, BLOOD COLLECTION
• Manufacturer (Section D): SMITHS MEDICAL ASD, INC.; 10 bowman dr; keene NH 03431
• Manufacturer Contact: reed covert ; 10 bowman drive; keene, NH 03431 ; 2247062300
• MDR Report Key: 21621823
• Report Number: 1217052-2025-00060
• Device Sequence Number: 6734281
• Product Code: JKA
• UDI-Device Identifier: 00351688060245
• UDI-Public: (01)00351688060245(17)261130(10)4467042
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: K952516
• 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
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 06/20/2025

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: G1470J
• Device Lot Number: 4467042
• Was Device Available for Evaluation?: Yes
• Date Returned to Manufacturer: 03/03/2025
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/19/2025
• Supplement Date Received by Manufacturer: 05/27/2025
• Initial Report FDA Received Date: 03/17/2025
• Supplement Report FDA Received Date: 06/20/2025
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 03/19/2024
• 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