MAUDE Adverse Event Report: QUEST MEDICAL, INC VRV-II VACUUM RELIEF VALVE; CPBP SUCTION CONTROL DEVICE

Model Number 4003203

Device Problem Leak/Splash (1354)

Patient Problem No Consequences Or Impact To Patient (2199)

Event Type  malfunction  

Manufacturer Narrative

There were no patient complications resulting from the alleged incident.An investigation will be conducted and a follow-up medwatch will be submitted if additional information is received.

Event Description

A report received states that the suction valve leaked during use in the hospital.The leak was noticed at the base of the dome.The valve was replaced with another valve.

Manufacturer Narrative

This mdr is a duplicate of report# 1649914-2017-00093 and was submitted in error.No further information will be provided.Please reference 1649914-2017-00093.

• Brand Name: VRV-II VACUUM RELIEF VALVE
• Type of Device: CPBP SUCTION CONTROL DEVICE
• Manufacturer (Section D): QUEST MEDICAL, INC; one allentown parkway; allen TX 75002
• Manufacturer (Section G): QUEST MEDICAL, INC.; one allentown parkway; allen TX 75002
• Manufacturer Contact: tosan onosode ; one allentown parkway; allen, TX 75002 ; 9723326338
• MDR Report Key: 7115434
• MDR Text Key: 94992227
• Report Number: 1649914-2017-00107
• Device Sequence Number: 1
• Product Code: DWD
• Combination Product (y/n): N
• Reporter Country Code: TU
• PMA/PMN Number: K760894
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: foreign,other
• Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date: 01/09/2018

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 12/13/2017
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: No Information
• Device Model Number: 4003203
• Device Lot Number: 050999
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: No
• Date Manufacturer Received: 11/22/2017
• Was Device Evaluated by Manufacturer?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Patient Outcome(s): Required Intervention