MAUDE Adverse Event Report: COOK INC HIGH PRESSURE CLEAR CONNECTING TUBE

Model Number	G09435
Health Effect - Clinical Code	Blood Loss (2597)
Date of Event	07/21/2015
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Common name: dtl adaptor, stopcock, manifold, fitting, cardiopulmonary bypass.Product code: dtl.This mdr is being filed after the associated complaint was reviewed under remediation protocol (b)(4), complaint/mdr retrospective review and remediation and reassessed as reportable.Additional complaint investigation and record remediation was not performed.
Event or Problem Description
It was reported that the cap from the high pressure tubing came off, and contrast media and blood sprayed out.Another device was used to complete the procedure successfully.The patient did not experience any adverse effects due to this occurrence.

• Brand Name: HIGH PRESSURE CLEAR CONNECTING TUBE
• Manufacturer (Section D): COOK INC; 750 daniels way; bloomington IN 47404
• MDR Report Key: 7476635
• Report Number: 1820334-2018-01343
• Device Sequence Number: 13501332
• Product Code: DTL
• UDI-Device Identifier: 00827002094352
• UDI-Public: (01)00827002094352(17)180520(10)5896763
• Combination Product (Y/N): N
• Initial Reporter State: OH
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 05/01/2018

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: G09435
• Device Catalogue Number: HTT14.5-120-P-FMRA
• Was Device Available for Evaluation?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/30/2018
• Initial Report FDA Received Date: 05/01/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1