MAUDE Adverse Event Report: Medline Industries, LP MEDLINE; SET,IRRIGATION,4-LEAD,90

Catalog Number	DYND19124
Medical Device Problem Code	Disconnection (1171)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	05/25/2023
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that "the issue is that the when the tubing connects with the cystoscope, our tubing is not staying on and is blowing out.".
Additional Manufacturer Narrative
The customer reported tur disconnection and stated that "tubing is popping off"; no patient harm or medical intervention was reported, and the patient was "fine." medline quality did not receive a sample nor photographs of the reported product, and a retrospective review of the past 6 months preceding the reported issue revealed 2 additional complaints of tur sets disconnecting with respect to the product.The issue was documented as unconfirmed because no samples nor photographs were made available to review, and a root cause could not be identified at that time; however, urology qa also stated this was a known defect documented by the vendor and urology qa and that complaints describing this issue would be confirmed.The documented known tubing issue was reported to be the result of a compromised batch of raw material from the vendor's supplier, and medline stated it would continue to monitor for the issue.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,4-LEAD,90
• Manufacturer (Section D): Medline Industries, LP; three lakes drive; northfield IL 60093 -275
• Manufacturer Contact: zelek alexander ; three lakes drive; northfield, IL 60093--275
• MDR Report Key: 50868786
• Report Number: 1417592-2026-48751
• Device Sequence Number: 9380242
• Product Code: LJH
• UDI-Device Identifier: 40080196993834
• UDI-Public: 40080196993834
• Combination Product (Y/N): N
• Initial Reporter State: CA
• 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): 09/22/2026

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: DYND19124
• Device Lot Number: 18322080001
• 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: 05/25/2023
• Initial Report FDA Received Date: 09/23/2026
• 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