MAUDE Adverse Event Report: Medline Industries, LP MEDLINE; GROUNDING, UNIVERS, SPLIT, 15'CORD

Catalog Number	PAD9165L
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	07/31/2023
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported that "they are having issues with the plug-in keeping signal and having to be held in.".
Additional Manufacturer Narrative
The customer reported issues with the plug-in keeping signal and having to be held in, and later stated, "i believe the one i sent had a broken plug." medline quality received one sample for evaluation, and visual inspection was conducted with provided sample; it was found the plug is broken in half.The reported concern was confirmed as the plug is broken, and the cause could not be determined with the received sample.The product has been confirmed to be at-risk for the esu plug breaking in half when the plug is removed from the grounding pad adhesive, and the division will continue to monitor the issue for trending.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: GROUNDING, UNIVERS, SPLIT, 15'CORD
• Manufacturer (Section D): Medline Industries, LP; three lakes drive; northfield IL 60093 -275
• Manufacturer Contact: kurian jokutty ; three lakes drive; northfield, IL 60093--275
• MDR Report Key: 50915276
• Report Number: 1417592-2026-51980
• Device Sequence Number: 12104945
• Product Code: GEI
• UDI-Device Identifier: 20193489082545
• UDI-Public: 20193489082545
• Combination Product (Y/N): N
• Initial Reporter State: IA
• 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): 09/26/2026

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: PAD9165L
• Was Device Available for Evaluation?: Yes
• Date Returned to Manufacturer: 08/28/2023
• 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: 07/31/2023
• Initial Report FDA Received Date: 09/28/2026
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• 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