MAUDE Adverse Event Report: BARD ACCESS SYSTEMS DOME SUBQ PORT, HICKMAN W; IMPLANTABLE PORT

Model Number	0602870
Medical Device Problem Codes	Component Incompatible (1108); Failure to Infuse (2340)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The device history records have been reviewed with special attention to the raw materials, subassemblies, manufacturing process and quality control testing.This lot met all release criteria.There was nothing found to indicate there was a manufacturing related cause for this event.The device has been returned for evaluation; the investigation is confirmed for the alleged failure to infuse.Based upon the available information, the definitive root cause is unknown.The device is labeled for single use.
Event or Problem Description
This report summarizes one (1) malfunction event.A review of the event indicated that model 0602870 implanted port experienced a component incompatibility and a failure to infuse.This event was reported from a single source.This event involved a patient with no reported injury.The patient was reported as a female weighing (b)(6) kgs whose age was not provided.

• Brand Name: DOME SUBQ PORT, HICKMAN W
• Common Device Name: IMPLANTABLE PORT
• Manufacturer (Section D): BARD ACCESS SYSTEMS; 605 n. 5600 w.; salt lake city UT 84116
• MDR Report Key: 8528530
• Report Number: 3006260740-2019-00973
• Device Sequence Number: 13935251
• Product Code: LJT
• UDI-Device Identifier: 00801741025778
• UDI-Public: (01)00801741025778
• Combination Product (Y/N): N
• Initial Reporter State: AZ
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 04/18/2019

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: No Information
• Device Model Number: 0602870
• Device Catalogue Number: 0602870
• Device Lot Number: REBS1423
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/31/2019
• Initial Report FDA Received Date: 04/18/2019
• Patient Sequence Number: 1