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U.S. Department of Health and Human Services

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

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BECTON DICKINSON MEDICAL SYSTEMS 3ML BD POSIFLUSH¿ HEPARIN LOCK FLUSH SYRINGE, IN 10ML SYRINGE, 10 USP UNITS/ML PREFILLED HEPARIN FLUSH SYRINGE Back to Search Results
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.
 
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Brand Name3ML BD POSIFLUSH¿ HEPARIN LOCK FLUSH SYRINGE, IN 10ML SYRINGE, 10 USP UNITS/ML
Type of DevicePREFILLED HEPARIN FLUSH SYRINGE
Manufacturer (Section D)
BECTON DICKINSON MEDICAL SYSTEMS
9630 south 54th street
franklin WI 53132
Manufacturer (Section G)
BECTON DICKINSON MEDICAL SYSTEMS
9630 south 54th street
franklin WI 53132
Manufacturer Contact
brett wilko
9450 south state street
sandy, UT 84070
8015652845
MDR Report Key7594793
MDR Text Key110856071
Report Number2134319-2018-00054
Device Sequence Number1
Product Code FOZ
Combination Product (y/n)N
Reporter Country CodeUS
PMA/PMN Number
K011967
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type other
Reporter Occupation
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 Received06/12/2018
Is this an Adverse Event Report? Yes
Is this a Product Problem Report? No
Device Operator Other
Device Catalogue Number306521
Device Lot NumberSEE H.10.
Was Device Available for Evaluation? No
Is the Reporter a Health Professional? No
Was the Report Sent to FDA?
Event Location No Information
Date Manufacturer Received05/23/2018
Was Device Evaluated by Manufacturer? Device Not Returned to Manufacturer
Is the Device Single Use? Yes
Is This a Reprocessed and Reused Single-Use Device? No
Type of Device Usage Unkown

Patient Treatment Data
Date Received: 06/12/2018 Patient Sequence Number: 1
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