MAUDE Adverse Event Report: CAREFUSION ALARIS SYRINGE MODULE; SET,ADMINISTRATION,INTRAVASCULAR

Model Number	10798696
Medical Device Problem Code	Fluid/Blood Leak (1250)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	10/03/2018
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Concomitant medical products: nonbd extension set; td (b)(6) 2018.The affected product has been received and the investigation is pending.A follow up report will be submitted once the failure investigation has been completed.
Event or Problem Description
The customer reported that the filter leaked during patient use.There was no patient harm.
Event or Problem Description
The customer reported that the filter leaked during patient use.There was no patient harm.
Additional Manufacturer Narrative
The customer¿s report of the filter leaking was confirmed.Visual inspection showed no anomalies.During functional testing a leak was observed from the filter outlet where the tubing and filter meet.The root cause of the customer¿s report of leaking from the filter was insufficient solvent application at the engagement between the filter outlet and tubing.

• Brand Name: ALARIS SYRINGE MODULE
• Common Device Name: SET,ADMINISTRATION,INTRAVASCULAR
• Manufacturer (Section D): CAREFUSION; 10020 pacific mesa blvd; san diego CA 92121 4386
• MDR Report Key: 8022467
• Report Number: 9616066-2018-02083
• Device Sequence Number: 1407556
• Product Code: FPA
• UDI-Device Identifier: 10885403234354
• UDI-Public: 10885403234354
• Combination Product (Y/N): N
• Initial Reporter State: AR
• Initial Reporter Country: US
• PMA/510(K) Number: K811885
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: health professional
• Initial Reporter Occupation: Nurse
• Type of Report: Initial,Followup
• Report Date (Section B): 10/03/2018

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: 04/18/2021
• Device Model Number: 10798696
• Device Catalogue Number: 10798696
• Device Lot Number: 18046218
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 10/26/2018
• Initial Date Received by Manufacturer: Not provided
• Supplement Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 10/30/2018
• Supplement Report FDA Received Date: 12/17/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: 10ML BD SYRINGE, 60ML BD SYRINGE,TD (B)(6) 2018; 8110,8015,PICC, SYRINGE, TD (B)(6) 2018; 8110,8015,PICC, SYRINGE, TD (B)(6) 2018
• Patient Age: 2 DA
• Patient Weight: 1