MAUDE Adverse Event Report: BARD ACCESS SYSTEMS EQUISTREAM ALPHACURVE DL CATHETER 14.5 FR, 28CM; DIALYSIS CATHETER

Model Number	5905280
Medical Device Problem Code	Defective Component (2292)
Health Effect - Clinical Code	No Patient Involvement (2645)
Date of Event	05/01/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The lot number of the device was provided.The device history records are currently under review.The return of the sample is pending.The investigation is currently underway.(expiration date: 03/2020).
Event or Problem Description
It was reported that upon opening the dialysis catheter insertion kit, the plastic tip of the tunneler was allegedly found to be broken.There was no patient contact.
Event or Problem Description
It was reported that upon opening the dialysis catheter insertion kit, the plastic tip of the tunneler was allegedly found to be broken.There was no patient contact.
Additional Manufacturer Narrative
Manufacturing review: the device history records have been reviewed and this lot met all release criteria.There was nothing found to indicate there was a manufacturing related cause for this event.Labeling review: a review of product labeling documents (e.G., procedural instructions, indications, warnings, precautions, cautions, possible complications, contraindications, nursing guide, and unit label) showed that the product labeling is adequate.Investigation summary: a sample evaluation could not be performed as the samples were not returned therefore the investigation is inconclusive due to the fact that no sample was returned for evaluation.The root cause could not be determined based upon available information.It is unknown whether patient and/or procedural factors contributed to the event.

• Brand Name: EQUISTREAM ALPHACURVE DL CATHETER 14.5 FR, 28CM
• Common Device Name: DIALYSIS CATHETER
• Manufacturer (Section D): BARD ACCESS SYSTEMS; 605 n. 5600 w.; salt lake city UT 84116
• MDR Report Key: 8670770
• Report Number: 3006260740-2019-01550
• Device Sequence Number: 10834049
• Product Code: MSD
• UDI-Device Identifier: 00801741013812
• UDI-Public: (01)00801741013812
• Combination Product (Y/N): N
• Initial Reporter State: ND
• Initial Reporter Country: US
• PMA/510(K) Number: K090101
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: user facility
• Initial Reporter Occupation: Non-Healthcare Professional
• Remedial Action: Recall
• Type of Report: Initial,Followup
• Report Date (Section B): 07/23/2019

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 Model Number: 5905280
• Device Catalogue Number: 5905280
• Device Lot Number: RECX2828
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 05/09/2019
• Supplement Date Received by Manufacturer: 06/28/2019
• Initial Report FDA Received Date: 06/05/2019
• Supplement Report FDA Received Date: 07/23/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1