MAUDE Adverse Event Report: BARD ACCESS SYSTEMS 55 CM 6 FR DL POWER PICC WITH SAFETY MI IN BASIC; PERCUTANEOUS IMPLANTED LONG TERM INTRAVASCULAR CATHETER

Catalog Number	3276118
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	02/04/2017
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The information provided by bard represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to bard.The device has not been returned to the manufacturer for evaluation.A lot history review (lhr) of rezh0786 showed no other similar product complaint(s) from this lot number.
Event or Problem Description
Facility reported interluminal communication or leaking between the lumens when injecting solution.No patient injury was reported.

• Brand Name: 55 CM 6 FR DL POWER PICC WITH SAFETY MI IN BASIC
• Common Device Name: PERCUTANEOUS IMPLANTED LONG TERM INTRAVASCULAR CATHETER
• Manufacturer (Section D): BARD ACCESS SYSTEMS; 605 n. 5600 w.; salt lake city UT 84116
• MDR Report Key: 6370740
• Report Number: 3006260740-2017-00172
• Device Sequence Number: 10881179
• Product Code: LJS
• UDI-Device Identifier: 00801741027994
• UDI-Public: (01)00801741027994(17)180828(10)REZH0786
• Combination Product (Y/N): N
• Initial Reporter Country: BR
• PMA/510(K) Number: K050931
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: other
• Initial Reporter Occupation: Health Professional
• Type of Report: Initial
• Report Date (Section B): 02/07/2017

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
• Operator of Device: Health Professional
• Device Expiration Date: 08/28/2018
• Device Catalogue Number: 3276118
• Device Lot Number: REZH0786
• Was Device Available for Evaluation?: No
• Event Location: Hospital
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 03/01/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1