MAUDE Adverse Event Report: Medline Industries, LP MEDLINE; 3-WY LOW PRSSRE SWIVEL LCK OFF

Catalog Number	DYNJSC301
Medical Device Problem Code	Fluid/Blood Leak (1250)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	07/16/2024
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that product is leaking at the hub.
Additional Manufacturer Narrative
The customer reported the product was leaking at the hub, and during a "facelift" the device was leaking "sterile fluid" with no patient involvement and no serious injury, medical intervention, or follow up care.No sample or photo was received for the investigation; the finished good device history records were reviewed and there were no line down situations, deviations, run-with outs, or non-conformance reports that might have had an impact on this issue.Because no sample or photo was received, the reported problem could not be evaluated through sample evaluation.Upon review of the dhr, the vendor lot number matches the identified defective lots, and root cause can be attributed to vendor design deviation; no adverse trend was identified.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: 3-WY LOW PRSSRE SWIVEL LCK OFF
• Manufacturer (Section D): Medline Industries, LP; three lakes drive; northfield IL 60093 -275
• Manufacturer Contact: pranay abbu ; three lakes drive; northfield, IL 60093--275
• MDR Report Key: 50882450
• Report Number: 1417592-2026-49694
• Device Sequence Number: 13218270
• Product Code: DTL
• UDI-Device Identifier: 40884389734569
• UDI-Public: 40884389734569
• Combination Product (Y/N): N
• Initial Reporter State: GA
• 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: DYNJSC301
• Device Lot Number: 23KBX198
• 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: Not provided
• Initial Report FDA Received Date: 09/24/2026
• 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