MAUDE Adverse Event Report: BARD ACCESS SYSTEMS MICROEZ SAFETY UNIVERSAL MICROINTRODUCER KIT WITH 3.5 FR PTFE INTRODUCER; CATHETER INTRODUCER

Model Number	0678935
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
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 rebt0084 showed no other similar product complaint(s) from this lot number.
Event or Problem Description
It was reported by the facility that when placing the picc the catheter creased mid shaft.The nurse used a device from another manufacturer to complete the procedure.No patient injury reported.

• Brand Name: MICROEZ SAFETY UNIVERSAL MICROINTRODUCER KIT WITH 3.5 FR PTFE INTRODUCER
• Common Device Name: CATHETER INTRODUCER
• Manufacturer (Section D): BARD ACCESS SYSTEMS; 605 n. 5600 w.; salt lake city UT 84116
• MDR Report Key: 7095591
• Report Number: 3006260740-2017-02215
• Device Sequence Number: 19157022
• Product Code: DYB
• UDI-Device Identifier: 00801741038365
• UDI-Public: (01)00801741038365
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K915167
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: user facility
• Initial Reporter Occupation: Nurse
• Type of Report: Initial
• Report Date (Section B): 12/07/2017

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 Model Number: 0678935
• Device Catalogue Number: 0678935
• Device Lot Number: REBT0084
• 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: 12/07/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1