MAUDE Adverse Event Report: B. BRAUN MEDICAL, INC. PERIFIX®; EPIDURAL ANESTHESIA KIT

Model Number	333512
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
Additional Manufacturer Narrative
(b)(4).The device involved has not been received for evaluation and the investigation is ongoing at this time.A follow up will be submitted when the investigation results become available.
Event or Problem Description
As per user facility via (b)(4): nursing staff noted that the epidural catheter came apart from the connector.The catheter was going into patient's back while patient was lying on the bed, becoming contaminated.The connection site was taped.The patient in this event required five (5) attempts before this catheter was successfully placed and became contaminated.No patient injury reported.
Additional Manufacturer Narrative
This report has been identified as b.Braun medical internal report number 400429592.No sample was received for further evaluation.Retains were pulled and tested.All testing was within specification.For continued safe use of the perifix catheter connector a detailed step-by-step instructions of how to use the perifix catheter connector label and cloth/silk medical tape has been provided.Review of the discrepancy management system (dsms) database was performed for the reported lot number and no abnormalities or non-conformances were noted during the in process or final product inspection.We will maintain this report for further references and continue to monitor other reports for similar occurrences.If any additional pertinent information becomes available, a follow up will be submitted.

• Brand Name: PERIFIX®
• Common Device Name: EPIDURAL ANESTHESIA KIT
• Manufacturer (Section D): B. BRAUN MEDICAL, INC.; 901 marcon blvd.; allentown PA 18109
• MDR Report Key: 8574875
• Report Number: 2523676-2019-00056
• Device Sequence Number: 16687535
• Product Code: OGE
• UDI-Device Identifier: 04046963899202
• UDI-Public: (01)04046963899202
• Combination Product (Y/N): N
• Initial Reporter State: MI
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: health professional,other,use
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 06/29/2019

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: 04/30/2021
• Device Model Number: 333512
• Device Catalogue Number: 333512
• Device Lot Number: 0061500330
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 04/16/2019
• Supplement Date Received by Manufacturer: 04/16/2019
• Initial Report FDA Received Date: 05/02/2019
• Supplement Report FDA Received Date: 06/29/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 25 YR
• Patient Weight: 125