MAUDE Adverse Event Report: ICU MEDICAL DE MEXICO, S. DE R.L. DE C.V. 7.5" TRIFUSE EXT SET W/3 MICROCLAVE® CLEAR, 4 CLAMPS (2 WHITE, BLUE, RED), LUER; STOPCOCK, I.V. SET

Catalog Number	MC33722
Medical Device Problem Code	Fluid/Blood Leak (1250)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	08/12/2024
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The device is not available for investigation.Without the return of the device a probable cause is unable to be determined.A device history review could not be completed due to the unknown lot number.
Event or Problem Description
The event involved a 7.5" trifuse ext set w/3 microclave® clear, 4 clamps (2 white, blue, red), luer lock where the customer reported that they have had many incidents of trifuse breaking off from the luer connection.All the breaks happened where the male luer lock inserts into the patient¿s microclave cap.This resulted in blood loss and ivf loss for the patients, chemo spills, and can potentially cause harm for the patients, however, specific information regarding volume of blood loss was not available but the customer did state that the majority of the blood loss was not substantial enough to require blood transfusion.There may have been some chemo exposure, but none required emergent care or treatment.However, additional information was received stating that they are unable to give accurate information about which broken extension tubing (bi/tri/quad fuse) had harm.Should additional information become available, a supplemental report will be provided.
Additional Manufacturer Narrative
The device was not returned for evaluation.A photo was provided and confirmed the complaint of the trifuse breaking off from the luer connection.Without the return of the used sample a comprehensive failure investigation cannot be performed, and a cause cannot be determined.Lot history review could not be performed as no lot information was provided.

• Brand Name: 7.5" TRIFUSE EXT SET W/3 MICROCLAVE® CLEAR, 4 CLAMPS (2 WHITE, BLUE, RED), LUER
• Common Device Name: STOPCOCK, I.V. SET
• Manufacturer (Section D): ICU MEDICAL DE MEXICO, S. DE R.L. DE C.V.; avenida cuarzo no. 250; ensenada, b.cfa. 22790 ; MX 22790
• Manufacturer Contact: reed covert ; 600 n. field dr.; lake forest, IL 60045 ; 2247062300
• MDR Report Key: 21702455
• Report Number: 9617594-2025-00564
• Device Sequence Number: 20998617
• Product Code: FMG
• UDI-Device Identifier: 00887709064942
• UDI-Public: 00887709064942
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: K964435
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional,Company Representative
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 05/07/2025

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: MC33722
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/26/2025
• Supplement Date Received by Manufacturer: 04/09/2025
• Initial Report FDA Received Date: 03/26/2025
• Supplement Report FDA Received Date: 05/07/2025
• 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
• Concomitant Medical Products and Therapy/Usage Dates: 3 BONDED MICROCLAVE CLEAR CAPS, ICU MEDICAL.; UNSPECIFIED MEDICATION, MFR UNK.
• Patient Sex: Unknown