MAUDE Adverse Event Report: ICU MEDICAL COSTA RICA LTD. PRIMARY PLUM SET, CLAVE SECONDARY PORT, POLYETHYLENE-LINED LIGHT RESISTANT TUBIN; SET, ADMINISTRATION, INTRAVASCULAR

Catalog Number	15339-28
Medical Device Problem Code	Fluid/Blood Leak (1250)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	04/01/2025
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The device has been received for evaluation.Investigation is pending.D4: only di provided as lot number is unknown.
Event or Problem Description
The event occurred on an unspecified date and involved a primary plum set, clave secondary port, polyethylene-lined light resistant tubing, clave y-site, secure lock, 103 inch where it was reported iv fluids leaked from the vent port above the drip chamber.There was patient involvement and no adverse event.
Additional Manufacturer Narrative
Investigation summary received one (1) used.List #15339-28, primary plum set, as received the filter vent was wetted out with prior infusate.As received the filter vent was wetted out.The set was leak tested per specifications, and leakage was observed.The complaint of leaking from the vent port above the drip chamber can be confirmed due to the wetted out filter.The probable cause of leakage is due to a temporary or complete loss of hydrophobic properties of the filter vent material due to an infusate interaction during use.A device history record lot # review could not be conducted because no lot number(s) was/were identified.

• Brand Name: PRIMARY PLUM SET, CLAVE SECONDARY PORT, POLYETHYLENE-LINED LIGHT RESISTANT TUBIN
• Common Device Name: SET, ADMINISTRATION, INTRAVASCULAR
• Manufacturer (Section D): ICU MEDICAL COSTA RICA LTD.; zona franca global; la aurora heredia ; CS
• Manufacturer Contact: reed covert ; 600 n. field dr.; lake forest, IL 60045 ; 2247062300
• MDR Report Key: 22064911
• Report Number: 9615050-2025-00246
• Device Sequence Number: 7812199
• Product Code: FPA
• UDI-Device Identifier: 00887709102361
• UDI-Public: 00887709102361
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K141789
• 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: Nurse
• Type of Report: Initial,Followup
• Report Date (Section B): 07/07/2025

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: 15339-28
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 05/07/2025
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/23/2025
• Supplement Date Received by Manufacturer: 06/09/2025
• Initial Report FDA Received Date: 05/21/2025
• Supplement Report FDA Received Date: 07/07/2025
• 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: VANILLA TPN, CAPS.
• Patient Sex: Unknown