MAUDE Adverse Event Report: CAREFUSION ALARIS® SYRINGE MODULE SET; 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	08/31/2018
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The affected product has been received and the evaluation is pending.A follow up report will be submitted once the evaluation is completed.
Event or Problem Description
The customer reported that the pressure sensor disc leaked during patient use.There was no patient harm.
Additional Manufacturer Narrative
The customer¿s report that the pressure sensing disc leaked was not confirmed but a leak at the filter outlet was confirmed.Visual inspection showed no anomalies.Functional testing resulted in leaking between the tubing and the distal end of the filter.The tubing was measured and found to be within specification.The root cause of the leak is insufficient solvent application at the engagement between the filter outlet and tubing.
Event or Problem Description
The customer reported that the pressure sensing disc leaked during patient use.There was no patient harm.
Event or Problem Description
The customer reported that the pressure sensing disc leaked during patient use in the nicu in room 13.There was no patient harm.
Additional Manufacturer Narrative
Patient dob provided, as well as, baby 1.

• Brand Name: ALARIS® SYRINGE MODULE SET
• Common Device Name: SET, ADMINISTRATION, INTRAVASCULAR
• Manufacturer (Section D): CAREFUSION; 10020 pacific mesa blvd; san diego CA 92121 4386
• MDR Report Key: 8078982
• Report Number: 9616066-2018-02275
• Device Sequence Number: 1887177
• 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: company representative,health
• Initial Reporter Occupation: Nurse
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 10/26/2018

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: 11/06/2018
• Initial Date Received by Manufacturer: Not provided
• Supplement Date Received by Manufacturer: Not provided; Not provided
• Initial Report FDA Received Date: 11/16/2018
• Supplement Report FDA Received Date: 12/19/2018; 01/17/2019
• 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: 8015,8110,BD SYRINGE 60ML, TD UNK; THERAPY DATE (B)(6) 2018; 8015,8110,BD SYRINGE 60ML, TD UNK
• Patient Age: 1 MO