MAUDE Adverse Event Report: B. BRAUN MELSUNGEN AG INTROCAN SAFETY®; CATHETER,INTRAVASCULAR,THE

Model Number	N/A
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Death (1802); Sepsis (2067)
Date of Event	03/21/2019
Type of Reportable Event	Death
Additional Manufacturer Narrative
Exemption number e2016018 b.Braun medical, inc.(importer) is submitting this report on behalf of b.Braun melsungen ag (manufacturer).This report has been identified as b.Braun melsungen ag internal report # (b)(4).We received 100 introcan safety-w pur 20g, 1.1x32mm-eu in original package.20 of the received samples were forwarded to the internal laboratory for a test on sterility.Device history record review (dhr): reviewed the device history record and no abnormalities found during in process and final control inspection.
Event or Problem Description
As reported by the user facility (translation of user facility information by bbm sales organization in france: catheter-infection catheter placed on (b)(6) 2019 and withdrawn on (b)(6) 2019.The catheter was maintained with a tegaderm dressing.The patient was re-hospitalized on (b)(6) 2019 with phlebitis.On (b)(6) 2019 the patient developed sepsis and was transferred to the icu.The patient died on (b)(6) 2019.
Additional Manufacturer Narrative
Exemption number e2016018.(b)(4).This report has been identified as b.Braun melsungen ag internal report # (b)(4).The samples were subjected to a test on sterility and growth promotion test.The samples correspond to the test for sterility.
Additional Manufacturer Narrative
Exemption number e2016018.B.Braun inc.(bbmi) (importer) is submitting the report on behalf of b.Braun melsungen ag (manufacturer).This report has been identified as b.Braun medical inc.Internal report number (b)(4).This follow up report is being filed to correct the branding, product code, and 510(k) information that was entered on the initial mdr.This report was filed for item number, 4253566-01, which is not sold in the united states, however a similar item number, 4253566-02, is sold in the united states by b.Braun medical, inc.The 510(k) has been updated to reflect a 510(k) that item 4253566-02 has been cleared under.

• Brand Name: INTROCAN SAFETY®
• Common Device Name: CATHETER,INTRAVASCULAR,THE
• Manufacturer (Section D): B. BRAUN MELSUNGEN AG; carl-braun-str. 1; melsungen, hessen 34212 ; GM 34212
• MDR Report Key: 8516311
• Report Number: 9610825-2019-00112
• Device Sequence Number: 2257314
• Product Code: FOZ
• UDI-Device Identifier: 04046964398971
• UDI-Public: (01)04046964398971
• Combination Product (Y/N): N
• Initial Reporter Country: FR
• PMA/510(K) Number: K020785
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: foreign,health professional
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 05/20/2019
• Report Date (Section F): 05/20/2019

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?: No
• Operator of Device: Health Professional
• Device Model Number: N/A
• Device Catalogue Number: 4253566-01
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 04/08/2019
• Was the Report Sent to FDA?: Yes
• Distributor Facility Aware Date: 04/15/2019
• Event Location: Hospital
• Date Report to Manufacturer: 05/20/2019
• Initial Date Received by Manufacturer: 03/22/2019
• Supplement Date Received by Manufacturer: 03/22/2019; 03/22/2019
• Initial Report FDA Received Date: 04/15/2019
• Supplement Report FDA Received Date: 05/14/2019; 05/20/2019
• 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: Death
• Patient Age: 88 YR
• Date Report Sent to FDA: 05/20/2019