MAUDE Adverse Event Report: Medline Industries, LP MEDLINE; DBD-SHOULDER PACK

Catalog Number	DYNJ69519B
Medical Device Problem Code	Contamination (1120)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	09/13/2024
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that "contaminated suction tubing in the shoulder pack".
Additional Manufacturer Narrative
The account reported finding foreign matter in suction tubing.A photo was received for the investigation, two photos and no physical sample was available, finished good production records were reviewed, finished good pack build was reviewed, and trending was reviewed.Medline observed the affected tubing with a foreign matter present on the exterior surface of the suction tip, confirming the reported issue.Based on the photo and pack build review, this item likely had the foreign matter residue on it prior to placement in the pack and was not noted during assembly; components may be received dirty from the supplier or can become dirty during transit or storage, 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: DBD-SHOULDER PACK
• Manufacturer (Section D): Medline Industries, LP; three lakes drive; northfield IL 60093 -275
• Manufacturer Contact: konstantina callas ; three lakes drive; northfield, IL 60093--275
• MDR Report Key: 50786523
• Report Number: 1417592-2026-41865
• Device Sequence Number: 10571781
• Product Code: OJH
• UDI-Device Identifier: 40195327608584
• UDI-Public: 40195327608584
• Combination Product (Y/N): N
• Initial Reporter State: TX
• 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): 09/14/2026

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: DYNJ69519B
• Device Lot Number: 24GBD762
• Was Device Available for Evaluation?: No
• 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: 09/13/2024
• Initial Report FDA Received Date: 09/16/2026
• Was Device Evaluated by Manufacturer? (Y/N): No
• Is the Device Labeled for Single Use? (Y/N): No
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Sex: Unknown