MAUDE Adverse Event Report: BARD ACCESS SYSTEMS POWERPICC CATHETER 6F BASIC TRAY (DUAL-LUMEN) (55CM); CATHETER,INTRAVASCULAR,THERAPEUTIC,LONG-TERM GREATER THAN 30 DAYS

Model Number	3276118
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
The information provided by bard represents all of the known information at this time.Despite good faith efforts to obtain additional information, the complainant / reporter was unable or unwilling to provide any further patient, product, or procedural details to bard.The device has not been returned to the manufacturer for evaluation, as the device was discarded after the event occurred.A lot history review (lhr) of reax1145 showed no other similar product complaint(s) from this lot number.
Event or Problem Description
It was reported that catheter power picc successfully passed through right braquial vein.It was stated that during the guide wire removing procedure, it left unwrapping one of each other and broke.When the catheter was totally removed, it was disintegrated.

• Brand Name: POWERPICC CATHETER 6F BASIC TRAY (DUAL-LUMEN) (55CM)
• Common Device Name: CATHETER,INTRAVASCULAR,THERAPEUTIC,LONG-TERM GREATER THAN 30 DAYS
• Manufacturer (Section D): BARD ACCESS SYSTEMS; 605 n. 5600 w.; salt lake city UT 84116
• MDR Report Key: 7842508
• Report Number: 3006260740-2018-02342
• Device Sequence Number: 11051718
• Product Code: LJS
• UDI-Device Identifier: 00801741027994
• UDI-Public: (01)00801741027994
• Combination Product (Y/N): N
• Initial Reporter Country: BR
• PMA/510(K) Number: K050931
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative
• Initial Reporter Occupation: Pharmacist
• Type of Report: Initial
• Report Date (Section B): 09/04/2018

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Health Professional
• Device Expiration Date: 10/31/2019
• Device Model Number: 3276118
• Device Catalogue Number: 3276118
• Device Lot Number: REAX1145
• Was Device Available for Evaluation?: No
• Event Location: Hospital
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 09/04/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention