MAUDE Adverse Event Report: BECTON DICKINSON MEDICAL SYSTEMS 10 ML BD¿ PRE-FILLED NORMAL SALINE SYRINGE, IN 10 ML SYRINGE; PREFILLED SALINE FLUSH SYRINGE

Catalog Number 306500

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

Patient Problems Bacterial Infection (1735); Unspecified Infection (1930)

Event Date 04/10/2018

Event Type  Injury  

Manufacturer Narrative

Fda notified?: the fda was made aware of this incident via voluntary medwatch 5077738.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 patient contacted an infection through her hickman line after receiving stem cells from her sister.The patient was admitted to the hospital from (b)(6) 2018 and again from (b)(6) 2018 and received antibiotics.The patient was positive for klebsiella and enterococcus.It is unknown if the patient herself used a bd device, but the patient's sister's picc line was flushed with a 10 ml bd¿ pre-filled normal saline syringe, in 10 ml syringe.Information regarding the patient sister is captured under a separate mdr report # 2134319-2018-00076.*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 (b)(4), there was no trend for infection cases reported for (b)(4) product.This complaint is part of a new trend which began in april 2018 capa 350041 was initiated to address this issue.There were no non-conformances, deviations, or out of specification conditions noted during the manufacture of lot 734211a that may have contributed to the reported infection.100% of 120 retained samples were visually inspected.No growth was seen (i.E., solution was clear).Lot 734211a was manufactured between lots 731012n and 735311n, both of which exhibited no growth during the confirmatory sterility testing.This, in combination with the daily environmental monitoring and original sterility testing for the lot release, provides confidence in the sterility of the complaint lot.A review of all lot sterility testing performed for product released between april 2015 & june 2018 confirmed that no organism growth was identified for any lots released during the shelf-life of this product.Investigation conclusion: the root cause analysis of the reported infection cases under capa 350041 has not identified a direct causation between the infections and the bd (b)(4) product.Capa 350041 has been initiated for this incident.

Event Description

It was reported that a patient contacted an infection through her hickman line after receiving stem cells from her sister.The patient was admitted to the hospital from (b)(6) 2018 and again from (b)(6) 2018 and received antibiotics.The patient was positive for klebsiella and enteroccus.It is unknown if the patient herself used a bd device, but the patient's sister's picc line was flushed with a 10 ml bd¿ pre-filled normal saline syringe, in 10 ml syringe.Information regarding the patient sister is captured under a separate mdr report # 2134319-2018-00076.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.

• Brand Name: 10 ML BD¿ PRE-FILLED NORMAL SALINE SYRINGE, IN 10 ML SYRINGE
• Type of Device: PREFILLED SALINE FLUSH SYRINGE
• Manufacturer (Section D): BECTON DICKINSON MEDICAL SYSTEMS; 9630 south 54th street; franklin WI 53132
• MDR Report Key: 7646318
• MDR Text Key: 112624216
• Report Number: 2134319-2018-00077
• Device Sequence Number: 1
• Product Code: FOZ
• UDI-Device Identifier: 30382903065005
• UDI-Public: 30382903065005
• Combination Product (y/n): N
• PMA/PMN Number: K011982
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: consumer,other
• Type of Report: Initial,Followup
• Report Date: 09/11/2018

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 06/28/2018
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Other
• Device Expiration Date: 12/07/2020
• Device Catalogue Number: 306500
• Device Lot Number: 734211A
• Was Device Available for Evaluation?: No
• Date Manufacturer Received: 06/08/2018
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Patient Outcome(s): Hospitalization; Required Intervention