MAUDE Adverse Event Report: Medline Industries, LP MEDLINE; DBQ-CEDIV ADMIN SET, 15DRP, 3 NF, 109

Catalog Number	DYNDTB1545
Medical Device Problem Code	Backflow (1064)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	07/22/2025
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that "fluid is backing up in the tubing.".
Additional Manufacturer Narrative
The account reported finding backflow, and the customer stated that fluid was backing up in the tubing.No sample or photo was received for investigation; finished good production records were reviewed, and the vendor did not find any discrepancies or defects in their production records or retained samples that could contribute to the defect described by the customer.Based on the complaint details and investigation, the complaint cannot be confirmed, and root cause has not been identified or determined because no picture or sample was provided for evaluation.The division will continue to monitor the issue for trending, and if a sample, photo, and/or additional information becomes available, this complaint will be reopened to be further investigated.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: DBQ-CEDIV ADMIN SET, 15DRP, 3 NF, 109
• Manufacturer (Section D): Medline Industries, LP; three lakes drive; northfield IL 60093 -275
• Manufacturer Contact: kim evangelista ; three lakes drive; northfield, IL 60093--275
• MDR Report Key: 50855688
• Report Number: 1417592-2026-47752
• Device Sequence Number: 21245501
• Product Code: FPA
• UDI-Device Identifier: 10197344098644
• UDI-Public: 10197344098644
• Combination Product (Y/N): N
• Initial Reporter State: SC
• Initial Reporter Country: US
• PMA/510(K) Number: K242126
• 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): 09/21/2026

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: DYNDTB1545
• Device Lot Number: BQ241157101
• 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: 07/22/2025
• Initial Report FDA Received Date: 09/22/2026
• 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