MAUDE Adverse Event Report: AMERICAN CONTRACT SYSTEMS, INC. ACS; GENERAL SURGERY TRAY

Model Number	CDMH06E
Health Effect - Clinical Code	No Patient Involvement (2645)
Date of Event	02/06/2019
Type of Reportable Event	Malfunction
Event or Problem Description
After pulling the blue wrapped pack (anterior hip pack) out of the clear packing a streak of what appeared to be dried blood was found on the sticker that keeps the blue wrap together.The pack was taken to the quality office.New pack obtained.This occurred prior to the patient entering the operating room.

• Brand Name: ACS
• Common Device Name: GENERAL SURGERY TRAY
• Manufacturer (Section D): AMERICAN CONTRACT SYSTEMS, INC.; 904 bethel circle; waunakee WI 53597
• MDR Report Key: 8343099
• Report Number: 8343099
• Device Sequence Number: 19237617
• Product Code: LRO
• UDI-Device Identifier: 00191072029324
• UDI-Public: (01)00191072029324(17)191212(10)654181
• Combination Product (Y/N): N
• Initial Reporter State: VA
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: User Facility
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 02/08/2019
• Report Date (Section F): 02/08/2019

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 Model Number: CDMH06E
• Device Lot Number: 654181
• Was Device Available for Evaluation?: Yes
• Was the Report Sent to FDA?: Yes
• Event Location: Hospital
• Date Report to Manufacturer: 02/15/2019
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 02/15/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Weight: 119
• Date Report Sent to FDA: 02/08/2019