MAUDE Adverse Event Report: HARSORIA HEALTHCARE MCKESSON BRANDS; CATHETER, IV SFTY SLIDING WINGED YLW 24GX3/4"

Catalog Number	200-IVSW2458
Medical Device Problem Code	Detachment of Device or Device Component (2907)
Health Effect - Clinical Code	Foreign Body Embolism (4439)
Date of Event	08/18/2025
Type of Reportable Event	Serious Injury
Event or Problem Description
It was reported by the customer that the full plastic tube portion of the iv came off in the patient's left arm.The patient was transferred to emergency room for surgery to remove.

• Brand Name: MCKESSON BRANDS
• Common Device Name: CATHETER, IV SFTY SLIDING WINGED YLW 24GX3/4"
• Manufacturer (Section D): HARSORIA HEALTHCARE; 110-111 phase iv; udyog vihar sector 18; gurugram, haryana 12201 5; IN 122015
• MDR Report Key: 22864266
• Report Number: 1451040-2025-00075
• Device Sequence Number: 12670579
• Product Code: QOI
• UDI-Device Identifier: 10612479267661
• UDI-Public: 10612479267661
• Combination Product (Y/N): N
• Initial Reporter State: MD
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Importer
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 08/21/2025
• Report Date (Section F): 08/21/2025

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Operator of Device: Health Professional
• Device Catalogue Number: 200-IVSW2458
• Device Lot Number: 99817
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Was the Report Sent to FDA?: Yes
• Distributor Facility Aware Date: 08/18/2025
• Device Age: 12 MO
• Event Location: Outpatient Treatment Facility
• Date Report to Manufacturer: 08/21/2025
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 08/21/2025
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Hospitalization; Required Intervention
• Patient Sex: Unknown
• Date Report Sent to FDA: 08/21/2025