MAUDE Adverse Event Report: QUICK-SET®; QUICK-SET 110/6

Lot Number	UNKNOWN
Medical Device Problem Code	Detachment of Device or Device Component (2907)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Type of Reportable Event	Malfunction
Event or Problem Description
(b)(4).Event occurred in (b)(6).It was reported that the tubing came out of the cannula.No further information available.

• Brand Name: QUICK-SET®
• Common Device Name: QUICK-SET 110/6
• MDR Report Key: 8468278
• Report Number: 3003442380-2019-00821
• Device Sequence Number: 2014909
• Product Code: FPA
• UDI-Device Identifier: 05705244006638
• UDI-Public: 05705244006638
• Combination Product (Y/N): N
• PMA/510(K) Number: K991759
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: distributor
• Initial Reporter Occupation: Other
• Type of Report: Initial

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: No Information
• Device Lot Number: UNKNOWN
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 05/12/2017
• Initial Report FDA Received Date: 04/01/2019
• Patient Sequence Number: 1