MAUDE Adverse Event Report: Medline Industries, LP MEDLINE; MANIFOLD,4-PORT,RIGHT,HAND,ON,500,PSI

Catalog Number	DYNJMAN05
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	07/01/2024
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that 1 ea of dynjman05, during a case a piece of the manifold broke off.
Additional Manufacturer Narrative
The customer reported a broken manifold during a case and stated that no one was harmed during the occurrence.No stock check was able to be performed as there was no remaining inventory, no sample was received for evaluation, and reviews of the finished good bill of materials/pack build, finished good manufacturing instructions, drawing, and device history record did not reveal any nonconformances related to the reported defect.Based on the above investigation results, the reported event was not able to be confirmed at this time.Root cause remains inconclusive at this time, and no action is required at this time as the reported event was not able to be confirmed.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: MANIFOLD,4-PORT,RIGHT,HAND,ON,500,PSI
• Manufacturer (Section D): Medline Industries, LP; three lakes drive; northfield IL 60093 -275
• Manufacturer Contact: joseph weiske ; three lakes drive; northfield, IL 60093--275
• MDR Report Key: 50870824
• Report Number: 1417592-2026-49114
• Device Sequence Number: 13430409
• Product Code: DTL
• UDI-Device Identifier: 40884389734934
• UDI-Public: 40884389734934
• Combination Product (Y/N): N
• Initial Reporter State: OH
• 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): 09/23/2026

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: DYNJMAN05
• Device Lot Number: 22KBU253
• 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: 07/01/2024
• 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