MAUDE Adverse Event Report: ICU MEDICAL DE MEXICO, S. DE R.L. DE C.V. CHEMOLOCK¿ BAG SPIKE WITH ADDITIVE PORT, CHEMOLOCK¿ PORT; CLOSED ANTINEOPLASTIC AND HAZARDOUS DRUG RECONSTITUTION AND TRANSFER SYSTEM

Catalog Number	CL3955
Medical Device Problem Codes	Fluid/Blood Leak (1250); Material Separation (1562)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	01/20/2025
Type of Reportable Event	Malfunction
Event or Problem Description
A complaint was received regarding a chemolock¿ bag spike with additive port, chemolock¿ port that experienced leakage during patient use.It was reported that chemo bag spike fell off, immediate spill of paclitaxel chemo straight down to iv.The date of incident was on 20-jan-2025.The report was submitted to manufacturer (icu medical) and vendor (cardinal health) with vendor reference number (b)(4).The product was not returned to manufacturer and is not available for evaluation.
Additional Manufacturer Narrative
The investigation is pending completion.Upon completion a supplemental mdr will be submitted.
Additional Manufacturer Narrative
No sample or photo/video received for investigation.The reported complaint of the chemo bag falling off could not be confirmed.Without the return of the sample or a photo/video, a comprehensive review cannot be performed and a probable cause cannot be determined.The lot history was reviewed.No nonconformities were identified that may have contributed to the reported complaint.Corrected information can be found in the concomitant products section e (throughout) and h6 component code.Additional contact information for section e: (b)(6).

• Brand Name: CHEMOLOCK¿ BAG SPIKE WITH ADDITIVE PORT, CHEMOLOCK¿ PORT
• Common Device Name: CLOSED ANTINEOPLASTIC AND HAZARDOUS DRUG RECONSTITUTION AND TRANSFER SYSTEM
• 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: 21939373
• Report Number: 9617594-2025-00869
• Device Sequence Number: 8836440
• Product Code: ONB
• UDI-Device Identifier: 00887709082502
• UDI-Public: (01)00887709082502(17)290101(10)13876379
• Combination Product (Y/N): N
• Initial Reporter Country: CA
• PMA/510(K) Number: K131549
• 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,Company Representative
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 06/03/2025

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: CL3955
• Device Lot Number: 13876379
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/02/2025
• Supplement Date Received by Manufacturer: 05/06/2025
• Initial Report FDA Received Date: 04/30/2025
• Supplement Report FDA Received Date: 06/03/2025
• Was Device Evaluated by Manufacturer? (Y/N): No
• Date Device Manufactured: 01/15/2024
• 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
• Concomitant Medical Products and Therapy/Usage Dates: PACLITAXEL CHEMO THEROPY, MFR UNKNOWN; PACLITAXEL, MFR UNKNOWN; UNSPECIFIED IV LINE, MFR UNK
• Patient Sex: Unknown