MAUDE Adverse Event Report: BECTON DICKINSON MEDICAL SYSTEMS SYR SAFETYLOK 10ML LL W/NDL 21X1-1/2 TW; HYPODERMIC SINGLE LUMEN NEEDLE

Catalog Number	305564
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	12/28/2018
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
A device evaluation is anticipated, but has not yet begun.Upon completion of the investigation, a supplemental report will be filed.
Event or Problem Description
It was reported that the syr safetylok 10ml ll w/ndl 21x1-1/2 tw experienced leakage around the plunger.
Additional Manufacturer Narrative
Investigation summary: no samples displaying the condition reported are available for examination.We were unable to fully investigate this incident, therefore a root cause could not be determined.Furthermore, a device history record review showed no rejected inspections or quality issues during the production of the provided lot number that could have contributed to the reported defect.
Event or Problem Description
It was reported that the syr safetylok 10ml ll w/ndl 21x1-1/2 tw experienced leakage around the plunger.

• Brand Name: SYR SAFETYLOK 10ML LL W/NDL 21X1-1/2 TW
• Common Device Name: HYPODERMIC SINGLE LUMEN NEEDLE
• Manufacturer (Section D): BECTON DICKINSON MEDICAL SYSTEMS; route 7 and grace way; canaan CT 06018
• MDR Report Key: 8358989
• Report Number: 1213809-2019-00253
• Device Sequence Number: 16623177
• Product Code: FMI
• UDI-Device Identifier: 30382903055648
• UDI-Public: 30382903055648
• Combination Product (Y/N): N
• Initial Reporter State: VA
• Initial Reporter Country: US
• PMA/510(K) Number: K944757
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: other,user facility
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 04/16/2019

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Operator of Device: Other
• Device Expiration Date: 05/31/2023
• Device Catalogue Number: 305564
• Device Lot Number: 8166897
• Initial Date Received by Manufacturer: 02/01/2019
• Supplement Date Received by Manufacturer: 02/01/2019
• Initial Report FDA Received Date: 02/21/2019
• Supplement Report FDA Received Date: 04/16/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other