MAUDE Adverse Event Report: B. BRAUN MELSUNGEN AG INTROCAN SAFETY®; CATHETER,INTRAVASCULAR,THE

Model Number	N/A
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	Device Embedded In Tissue or Plaque (3165)
Date of Event	06/19/2018
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Exemption number e2016018 b.Braun medical, inc.(importer) is submitting this report on behalf of b.Braun melsungen ag (manufacturer).This report has been identified as b.Braun melsungen ag internal report # (b)(4).No sample has been returned for investigation.Without the actual sample (or device), a thorough investigation could not be performed and no specific conclusion can be drawn as to the cause of the reported event.If the sample and/or additional pertinent information becomes available, a follow up report will be submitted.Device history record (dhr): reviewed the dhr and no abnormality observed during in-process and at final control inspection.
Event or Problem Description
As reported by the user facility (translation of user facility information by bbm sales organization in colombia: part of the medical device into patient.
Additional Manufacturer Narrative
Exemption number e2016018.B.Braun medical, inc.(importer) is submitting this report on behalf of b.Braun melsungen ag (manufacturer).This report has been identified as b.Braun melsungen ag internal report # (b)(4).We received one used capillary part of an introcan safety pur 22g, 0.9x25mm-sa without packaging.The needle, the capillary housing and the protective cap were not handed over by the customer.The returned capillary was taken to a visual inspection.The capillary is cut off approximately 24 mm behind the capillary tip.The surface of the cut and the shape of this area leads to the assumption that this damages is caused by a pair of scissors.Further one, the capillary was penetrated by the cannula approximately 16 mm away from the capillary tip.The area of the puncture shows a v-shaped damage.This puncture was caused by the cannula by withdrawing and pushing forward again.According to both damages, we assume a problem during application.Therefore this complaint is not confirmed.The complained sample was forwarded to our manufacturing site for evaluation: cut off capillary defect most likely not appear to be attributed by manufacturing process as the defect is able to be detected by the in-line vision system.Damages induced after assembly process is not possible since the catheter had been protected with the protective cap.The simulation by cannula reinsertion did not produce similar defect as per complaint sample.The complaint sample defect matches with the simulation sample of being cut by sharp object such as a scissors or scalpel.The defect on the complaint sample is believed to be occurred after the cannulation process due to been cut by a sharp tool.As communicated in ifu, warning section stated that: after withdrawal, do not reintroduce the steel needle into the catheter, as the latter may be cut off, leading to catheter embolism.Do not use scissors or sharp instruments at or near the insertion site.Cause : defect due to wrong handling.
Additional Manufacturer Narrative
Exemption number e2016018.B.Braun inc.(bbmi) (importer) is submitting the report on behalf of b.Braun melsungen ag (manufacturer).This report has been identified as b.Braun medical inc.Internal report number (b)(4).This report was filed for item number, 4251628-04, which is not sold in the united states, however a similar item number, 4251628-02, is sold in the united states by b.Braun medical, inc.The 510(k) has been updated to reflect a 510(k) that item 4251628-02 has been cleared under.Note: b.Braun is aware that the listed exemption has been withdrawn, however since the initial mdr report was filed under this exemption, the follow up is also being filed under the exemption.

• Brand Name: INTROCAN SAFETY®
• Common Device Name: CATHETER,INTRAVASCULAR,THE
• Manufacturer (Section D): B. BRAUN MELSUNGEN AG; carl-braun-str. 1; melsungen, hessen 34212 ; GM 34212
• MDR Report Key: 7916716
• Report Number: 9610825-2018-00204
• Device Sequence Number: 1488869
• Product Code: FOZ
• UDI-Device Identifier: 04046964399091
• UDI-Public: (01)04046964399091(17)230101(10)18A31G8913
• Combination Product (Y/N): N
• Initial Reporter Country: CO
• PMA/510(K) Number: K020785
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: foreign,health professional
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 07/03/2019
• Report Date (Section F): 07/03/2019

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 Expiration Date: 01/01/2023
• Device Model Number: N/A
• Device Catalogue Number: 4251628-04
• Device Lot Number: 18A31G8913
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 10/04/2018
• Was the Report Sent to FDA?: Yes
• Distributor Facility Aware Date: 09/27/2018
• Device Age: 8 MO
• Event Location: Hospital
• Date Report to Manufacturer: 07/03/2019
• Initial Date Received by Manufacturer: 09/10/2018
• Supplement Date Received by Manufacturer: 09/10/2018; 09/10/2018
• Initial Report FDA Received Date: 09/27/2018
• Supplement Report FDA Received Date: 12/14/2018; 07/03/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Date Report Sent to FDA: 07/03/2019