MAUDE Adverse Event Report: CAREFUSION 16 IN NON-DEHP STANDARD BORE EXTENSION SET; SET, ADMINISTRATION, INTRAVASCULAR

Model Number	MX9166
Medical Device Problem Code	Fluid/Blood Leak (1250)
Health Effect - Clinical Code	No Information (3190)
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Concomitant medical products: non bd primary tubing set.The affected product has been received and the investigation is pending.A follow up report will be submitted once the failure investigation has been completed.Patient age and dob requested but not provided, however the event was reported to have occurred on the pediatric oncology department, therefore it is presumed that the patient was a pediatric patient.
Event or Problem Description
It was reported that the tubing set filter was found to have leaked from the "circle area" on the backside of the filter after the completion of a chemotherapy infusion in the pediatric oncology department.
Additional Manufacturer Narrative
The customer¿s report that the tubing set filter leaked from the vent was not confirmed.Visual inspection of the set noted no damage or any issues.Functional and pressure testing resulted in no leaking.The root cause of the leak was not identified.
Event or Problem Description
It was reported that the tubing set filter was found to have leaked from the "circle area" on the backside of the filter after the completion of a chemotherapy infusion in the pediatric oncology department.

• Brand Name: 16 IN NON-DEHP STANDARD BORE EXTENSION SET
• Common Device Name: SET, ADMINISTRATION, INTRAVASCULAR
• Manufacturer (Section D): CAREFUSION; 10020 pacific mesa blvd; san diego CA 92121 4386
• MDR Report Key: 8907426
• Report Number: 9616066-2019-02300
• Device Sequence Number: 16823378
• Product Code: FPA
• UDI-Device Identifier: 10885403237652
• UDI-Public: 10885403237652
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• PMA/510(K) Number: K051499
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: company representative,health
• Initial Reporter Occupation: Non-Healthcare Professional
• 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 Expiration Date: 01/30/2024
• Device Model Number: MX9166
• Device Catalogue Number: MX9166
• Device Lot Number: 19017181
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 08/01/2019
• Initial Date Received by Manufacturer: Not provided
• Supplement Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 08/19/2019
• Supplement Report FDA Received Date: 08/21/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: 8015,8100,BD SPIROS ADAPTER, TD UNK.