MAUDE Adverse Event Report: SMITHS MEDICAL ASD, INC. JELCO® HYPODERMIC NEEDLE-PRO® DEVICE; NEEDLE, HYPODERMIC, SINGLE LUMEN

Catalog Number	4293
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Codes	Device Embedded In Tissue or Plaque (3165); No Information (3190)
Date of Event	07/17/2017
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Additional information regarding the event has been requested, but not yet received.
Event or Problem Description
It was reported that the needle of a jelco® hypodermic needle-pro® device "broke off".It was noted that an adverse event occurred, however details of the event were not provided.
Additional Manufacturer Narrative
A box of jelco® hypodermic needle-pro® devices was returned for investigation.Visual inspection did not reveal any defects or anomalies.No breakage or bent components were observed.Functional testing was performed and there was no leakage or separation or breakage of the components.The complaint was not confirmed and no root cause was identified.
Event or Problem Description
It was additionally reported that the device was in use for joint injections in the knee with the drug orthovisc.The plastic part at the base of the needle broke causing the needle to stay in the patient's knee.The needle was able to be removed without harm.

• Brand Name: JELCO® HYPODERMIC NEEDLE-PRO® DEVICE
• Common Device Name: NEEDLE, HYPODERMIC, SINGLE LUMEN
• Manufacturer (Section D): SMITHS MEDICAL ASD, INC.; 6000 nathan lane north; minneapolis MN 55442
• MDR Report Key: 6797972
• Report Number: 3012307300-2017-01833
• Device Sequence Number: 13845092
• Product Code: FMI
• UDI-Device Identifier: 20351688058901
• UDI-Public: 20351688058901
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K923127
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: distributor
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 09/27/2017

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Physician
• Device Expiration Date: 04/26/2022
• Device Catalogue Number: 4293
• Device Lot Number: 3416022
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 08/23/2017
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 07/28/2017
• Supplement Date Received by Manufacturer: 09/01/2017; 09/15/2017
• Initial Report FDA Received Date: 08/16/2017
• Supplement Report FDA Received Date: 09/15/2017; 09/27/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other