MAUDE Adverse Event Report: BECTON DICKINSON MEDICAL SYSTEMS 3ML BD POSIFLUSH¿ HEPARIN LOCK FLUSH SYRINGE, IN 10ML SYRINGE, 10 USP UNITS/ML; PREFILLED HEPARIN FLUSH SYRINGE

Catalog Number 306521

Device Problems Nonstandard Device (1420); Microbial Contamination of Device (2303)

Patient Problem Bacterial Infection (1735)

Event Date 03/13/2018

Event Type  Injury  

Manufacturer Narrative

Eleven potential lot numbers were provided for this incident.The information for each lot number is as follows: medical device lot #: 710071n, medical device expiration date: 10/9/2018, device manufacture date: 4/10/2017.Medical device lot #: 711571n, medical device expiration date: 10/24/208, device manufacture date: 4/25/2017.Medical device lot #: 712271n, medical device expiration date: 11/1/2018, device manufacture date: 5/2/2017.Medical device lot #: 716771n, medical device expiration date: 12/12/2018, device manufacture date: 6/16/2017.Medical device lot #: 717071n, medical device expiration date: 12/18/2018, device manufacture date: 6/19/2017.Medical device lot #: 718091n, medical device expiration date: 12/28/2018, device manufacture date: 6/26/2017.Medical device lot #: 721481n, medical device expiration date: 2/1/2019, device manufacture date: 8/2/2017.Medical device lot #: 726391n, medical device expiration date: 3/19/2019, device manufacture date: 9/20/2017.Medical device lot #: 726472n, medical device expiration date: 3/20/2019, device manufacture date:9/21/2017.Medical device lot #: 726571n, medical device expiration date: 3/21/2019, device manufacture date: 9/22/2017.Medical device lot #: 726871n, medical device expiration date: 3/24/2019, device manufacture date: 9/25/2017.A device evaluation is anticipated, but has not yet begun.Upon completion of the investigation, a supplemental report will be filed.

Event Description

It was reported that a (b)(6) male patient with a diagnosis of neuroblastoma and a tunneled central line had a positive blood culture for serratia marcescens on (b)(6) 2018.The patient was treated and discharged.The pfge patterns for this incident are indistinguishable from the original co outbreak pattern.The device implicated with this incident is a 3 ml bd posiflush¿ heparin lock flush syringe, in 10 ml syringe, 10 usp units/ml.*out of an abundance of caution and in the interest of public health, bd voluntarily recalled certain lots of bd posiflush¿ heparin lock flush and bd¿ pre-filled normal saline flush syringes due to a potential for contamination with serratia marcescens bacterium.Bd was notified by the u.S.Food and drug administration (fda) and centers for disease control and prevention (cdc) about a potential epidemiological link between catheter related blood stream infections and the s.Marcescens bacterium.Specifically, the fda and cdc identified a potential connection between reports of infection in a small number of patients caused by s.Marcescens across multiple states.Cdc¿s initial investigation found that affected patients had received treatment using certain bd flush products.To date, there is no evidence of bd flush product testing positive for this bacterium.Investigations are ongoing by bd, fda, and cdc.

Event Description

It was reported that a 12 year old male patient with a diagnosis of neuroblastoma and a tunneled central line had a positive blood culture for serratia marcescens on 3/13/2018.The patient was treated and discharged.The pfge patterns for this incident are indistinguishable from the original co outbreak pattern.The device implicated with this incident is a 3ml bd posiflush¿ heparin lock flush syringe, in 10ml syringe, (b)(4) usp units/ml.Out of an abundance of caution and in the interest of public health, bd voluntarily recalled certain lots of bd posiflush¿ heparin lock flush and bd¿ pre-filled normal saline flush syringes due to a potential for contamination with serratia marcescens bacterium.Bd was notified by the u.S.Food and drug administration (fda) and centers for disease control and prevention (cdc) about a potential epidemiological link between catheter related blood stream infections and the s.Marcescens bacterium.Specifically, the fda and cdc identified a potential connection between reports of infection in a small number of patients caused by s.Marcescens across multiple states.Cdc¿s initial investigation found that affected patients had received treatment using certain bd flush products.To date, there is no evidence of bd flush product testing positive for this bacterium.Investigations are ongoing by bd, fda, and cdc.

Manufacturer Narrative

H.6.Investigation summary: prior to the report of infection evaluated in mps-18-1248-sa, there was no trend for infection cases reported for franklin product.This complaint is part of a new trend which began in april 2018.(b)(4) was initiated to address this issue.Although a definitive lot # was not provided, a general dhr review was performed of the potential lots listed.There were no deviations or non-conformances that occurred during the manufacture of the potential lots listed.The sterility lot test for the potential lots were all acceptable (no growth exhibited).No samples returned.A review of all lot sterility testing performed for product released between april 2015 & may 2018 confirmed that no organism growth was identified for any lots released during the shelf life of this product.Investigation conclusion: the root cause of the reported infection cases under (b)(4) has not identified a direct causation between the infections and the bd franklin product.(b)(4) has been initiated for this issue.

• Brand Name: 3ML BD POSIFLUSH¿ HEPARIN LOCK FLUSH SYRINGE, IN 10ML SYRINGE, 10 USP UNITS/ML
• Type of Device: PREFILLED HEPARIN FLUSH SYRINGE
• Manufacturer (Section D): BECTON DICKINSON MEDICAL SYSTEMS; 9630 south 54th street; franklin WI 53132
• MDR Report Key: 7594793
• MDR Text Key: 110856071
• Report Number: 2134319-2018-00054
• Device Sequence Number: 1
• Product Code: FOZ
• UDI-Device Identifier: 30382903065210
• UDI-Public: 30382903065210
• Combination Product (y/n): N
• PMA/PMN Number: K011967
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: other
• Type of Report: Initial,Followup
• Report Date: 09/07/2018

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 06/12/2018
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Other
• Device Catalogue Number: 306521
• Device Lot Number: SEE H.10.
• Was Device Available for Evaluation?: No
• Date Manufacturer Received: 05/23/2018
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Patient Outcome(s): Required Intervention
• Patient Age: 12 YR