MAUDE Adverse Event Report: FRAZIER; APPARATUS, SUCTION, OPERATING-ROOM, WALL VACUUM POWERED

Catalog Number	0033120
Medical Device Problem Code	Delivered as Unsterile Product (1421)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Type of Reportable Event	Malfunction
Event or Problem Description
During incoming inspection, the distributor rejected this device, 0033120, for an insufficient heatseal.There was no contact with the patient as this was found during incoming inspection.This will be reported as a malfunction with potential for injury upon reoccurrence.
Additional Manufacturer Narrative
Received three of 0033120 in original packaging.Lot number was verified.Performed a visual inspection of the devices, there were no obvious signs of a breach.Performed a functional inspection, the devices were dye leak tested per tm-10-217 rev.F which indicated that one of the packages had an insufficient heat seal.The two other packages had sufficient heat seals.Root cause cannot be determined, however, based upon the manufacturing process review; a possible cause of this event could be a breach by the tip of the device during transportation or storage.The manufacturing documents from the device history record have been reviewed with special attention to the manufacturing and inspection of the product.The product released for distribution was found to have met all specifications prior to shipment.(b)(4).We will continue to monitor per regulatory requirements to help ensure patient safety.

• Brand Name: FRAZIER
• Common Device Name: APPARATUS, SUCTION, OPERATING-ROOM, WALL VACUUM POWERED
• Manufacturer Contact: madeline ; 11311 concept blvd; largo, FL 33773 ; 7274708358
• MDR Report Key: 21908612
• Report Number: 1320894-2025-00115
• Device Sequence Number: 4084633
• Product Code: GCX
• UDI-Device Identifier: 30653405000147
• UDI-Public: (01)30653405000147(17)280422(10)202304241
• Combination Product (Y/N): N
• Initial Reporter Country: JA
• PMA/510(K) Number: EXEMPT
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Foreign,Distributor
• Initial Reporter Occupation: Administrator/Supervisor
• Type of Report: Initial
• Report Date (Section B): 04/24/2025

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: Other
• Device Catalogue Number: 0033120
• Device Lot Number: 202304241
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 04/22/2025
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/22/2025
• Initial Report FDA Received Date: 04/25/2025
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 04/24/2023
• 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
• Patient Sequence Number: 1
• Patient Sex: Unknown
• Patient Ethnicity: Non Hispanic