MAUDE Adverse Event Report: EPIC INTERNATIONAL (THAILAND) CO., LTD. SMARTEZ PUMP; ELASTOMERIC PUMP

Model Number	481012
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	12/11/2018
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Based on the descriptions of the event by user facility, the device functions normally.The initial observation of no flow could be due to poor connection with connector used on patient side.Device history record for the reported lot number was reviewed and confirmed that the lot was manufactured according to the approved manufacturing procedures.Retained samples were also tested and flow normally.
Event or Problem Description
Smartez pump (se0200-100, lot# s8e46) containing daptomycin350 mg in 0.9% sodium chloride 100 ml would not infuse.Line flushing without problem.Rn disconnected/ reflushed / reconnected and then it eventually infused.

• Brand Name: SMARTEZ PUMP
• Common Device Name: ELASTOMERIC PUMP
• Manufacturer (Section D): EPIC INTERNATIONAL (THAILAND) CO., LTD.; hemaraj eastern seaboard indus; 500/73 moo 2, tasit; pluakdaeng, rayong 21140 ; TH 21140
• MDR Report Key: 8350448
• Report Number: 3012429465-2019-00055
• Device Sequence Number: 11334732
• Product Code: MEB
• UDI-Device Identifier: 28859299101013
• UDI-Public: (01)28859299101013(10)S8E46(17)210428(11)180528(241)SE0200-100
• Combination Product (Y/N): N
• Initial Reporter Country: US
• PMA/510(K) Number: K151650
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: distributor,foreign,health pr
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 01/25/2019

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: 04/28/2021
• Device Model Number: 481012
• Device Lot Number: S8E46
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 01/15/2019
• Initial Report FDA Received Date: 02/19/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1