MAUDE Adverse Event Report: BARD ACCESS SYSTEMS POWERPORT MRI ISP ALTERNATIVE BUMPS, 8F GROSHONG, WO SP; IMPLANTABLE PORT

Model Number	4808561
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
As the lot number for the device was provided, a manufacturing review will be performed.The sample was not returned to the manufacturer for inspection/evaluation.Therefore, the investigation of the reported event is inconclusive.Based upon the available information, the definitive root cause for this event is unknown.The instructions for use (ifu) is adequate for the reported device/patient code(s) and provides general instructions for use, as well as warnings, precautions and potential complications associated with the device.Upon receipt of new or additional information, a follow-up report will be submitted as applicable.
Event or Problem Description
This report summarizes one malfunction.A review of the reported information indicated that model 4808561.Implantable port allegedly experienced break.This report was received from a single source.This event did involve patient with no reported patient injury.The patient is 77 years of age, the gender is male; however, the weight was not provided.

• Brand Name: POWERPORT MRI ISP ALTERNATIVE BUMPS, 8F GROSHONG, WO SP
• Common Device Name: IMPLANTABLE PORT
• Manufacturer (Section D): BARD ACCESS SYSTEMS; 605 n. 5600 w.; salt lake city UT 84116
• MDR Report Key: 8803043
• Report Number: 3006260740-2019-02015
• Device Sequence Number: 2693353
• Product Code: LJT
• UDI-Device Identifier: 00801741027352
• UDI-Public: (01)00801741027352
• 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): 07/18/2019

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: 4808561
• Device Catalogue Number: 4808561
• Device Lot Number: RECW0344
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 06/30/2019
• Initial Report FDA Received Date: 07/18/2019
• Patient Sequence Number: 1