MAUDE Adverse Event Report: Medline Industries, LP MEDLINE; ANGIO PACK

Catalog Number	DYNJ82224C
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	12/04/2024
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that "we just encountered another manifold that broke.".
Additional Manufacturer Narrative
The customer reported that when "clipping them onto the bowl" while setting up the sterile table "they are breaking" and that the incident happens prior to the procedure beginning with no patient involvement.Finished good production records were reviewed and there were no line down situations, run without approvals, deviations or non-conformance reports that might have had an impact on this issue; finished good pack build was reviewed and there were no issues with the build that likely contributed to the reported issue.No sample or photo was received for the investigation, and the defect could not be confirmed.The cause was unconfirmed, sample required to determine cause, and the supplier quality team will monitor this issue for trending purposes.There were no reports of death, serious injury, medical intervention, or follow up care.It has been determined that the reported event could cause or contribute to serious injury if it were to occur again.In an abundance of caution, this is a reportable event.If additional information becomes available this report will be reopened and reevaluated.This medical device report (mdr) is being submitted as part of retrospective review activities, which include review of historical data in accordance with regulations at 21 cfr part 803.The information included in this mdr reflects the information reasonably known to the manufacturer at the time of this retrospective review and submission.

• Brand Name: MEDLINE
• Common Device Name: ANGIO PACK
• Manufacturer (Section D): Medline Industries, LP; three lakes drive; northfield IL 60093 -275
• Manufacturer Contact: arundathi nomula ; three lakes drive; northfield, IL 60093--275
• MDR Report Key: 50274805
• Report Number: 1417592-2026-17837
• Device Sequence Number: 13407846
• Product Code: OES
• UDI-Device Identifier: 10195327642020
• UDI-Public: 10195327642020
• Combination Product (Y/N): N
• Initial Reporter State: IL
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Type of Report: Initial
• Report Date (Section B): 08/14/2026

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
• Device Catalogue Number: DYNJ82224C
• Device Lot Number: 24IMG243
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 01/24/2025
• Initial Report FDA Received Date: 08/17/2026
• Was Device Evaluated by Manufacturer? (Y/N): No
• 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