MAUDE Adverse Event Report: Medline Industries, LP MEDLINE; SET,IRRIGATION,CYSTO,Y-TYPE,90

Catalog Number	DYND19122
Medical Device Problem Code	Material Puncture/Hole (1504)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	11/29/2023
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that 4 of the tubes had holes in them.The holes were reported to be up before the fill chamber.
Additional Manufacturer Narrative
The customer reported "4 tubes with holes" and stated, "the holes were reported to be up before the fill chamber." medline quality did not receive a sample nor photographs of the reported product; a retrospective review of the past 6 months preceding the reported issue revealed no additional complaints of damaged product with respect to the product, and there are currently no known trends for this product.The issue is unconfirmed, as no samples nor photographs were made available to review, and a root cause cannot be identified at this time.Due to the inability to confirm the complaint, as well as the low reported occurrence rate for this issue, no further corrective action is necessary at this time.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: SET,IRRIGATION,CYSTO,Y-TYPE,90
• Manufacturer (Section D): Medline Industries, LP; three lakes drive; northfield IL 60093 -275
• Manufacturer Contact: azra halilovic ; three lakes drive; northfield, IL 60093--275
• MDR Report Key: 50802626
• Report Number: 1417592-2026-43337
• Device Sequence Number: 12924879
• Product Code: LJH
• UDI-Device Identifier: 40080196993827
• UDI-Public: 40080196993827
• Combination Product (Y/N): N
• Initial Reporter State: TN
• Initial Reporter Country: US
• PMA/510(K) Number: K970946
• 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): 09/16/2026

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: DYND19122
• Device Lot Number: 0332305A138
• 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: 11/29/2023
• Initial Report FDA Received Date: 09/17/2026
• 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