MAUDE Adverse Event Report: JMS SINGAPORE PTE LTD WINGEATER A. V. FISTULA 15G X 1" BE WITH CLAMP; FISTULA NEEDLE

Model Number	820-5002-33
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Hemolysis (1886)
Date of Event	06/19/2019
Type of Reportable Event	Serious Injury
Event or Problem Description
An area technical operations manager (atom) reported that a hemodialysis patient experienced hemolysis event.Upon follow up, the hemolysis event appears to have occurred between (b)(6) 2019.The patient's pre-hemodialysis treatment labs were drawn on (b)(6) 2019 without any reported issues with the lab specimen.On (b)(6) 2019, the clinic manager reviewed the lab results which were drawn post hemodialysis treatment and noticed the patient had a drop in their baseline hemoglobin from 8.9 to 7.2.The patient was admitted into the hospital due to weakness on (b)(6) 2019 with a hemoglobin of 5.9 and positive schistocytes.The patient required a blood transfusion.The patient was discharged on (b)(6) 2019.Further details regarding the patient's hospitalization are currently unknown.Reportedly, the patient continues to receive hemodialysis treatments.The patient was reported dialyzing with a fresenius 2008t hemodialysis machine, fresenius bloodlines, fresenius 160 and 180 dialyzers, fresenius granuflo acid (2551) 2.0 potassium/2.5 calcium, fresenius naturalyte 4000 bicarbonate, fresenius clic blood chamber and fresenius normal saline.It was reported there were no visual defects or anything unexpected with any of the fresenius products used, as well as no machine alarms, clotting events and/or dialyzer leaks in relation to the hemolysis event.It was reported there was nothing unusual in any of the hemodialysis treatments.There were no visible signs of hemolysis during any treatment such as, translucent/cherry colored blood (which is typical with hemolysis in hemodialysis) or any patient symptoms.The patient completed all their hemodialysis treatments during the timeframe without any adverse effect.Currently, the cause of the hemolysis event is unknown.The actual and companion samples of the fresenius products used between (b)(6) 2019 have been sent to the manufacturer for further investigation.This was brought to our attention on (b)(6) 2019 and as of (b)(6) 2019 no cause of hemolysis was determined.

• Brand Name: WINGEATER A. V. FISTULA 15G X 1" BE WITH CLAMP
• Common Device Name: FISTULA NEEDLE
• Manufacturer (Section D): JMS SINGAPORE PTE LTD; 440 ang mo kio; industrial park 1; singapore, 56962 0; SN 569620
• MDR Report Key: 9014463
• Report Number: 2954317-2019-00003
• Device Sequence Number: 2503385
• Product Code: FIE
• UDI-Device Identifier: 08888483005291
• UDI-Public: 08888483005291
• Combination Product (Y/N): N
• Initial Reporter State: KY
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Importer
• Initial Reporter Occupation: Administrator/Supervisor
• Type of Report: Initial
• Report Date (Section B): 09/12/2019
• Report Date (Section F): 09/12/2019

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Health Professional
• Device Expiration Date: 11/12/2023
• Device Model Number: 820-5002-33
• Device Lot Number: 181112351
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Distributor Facility Aware Date: 08/19/2019
• Device Age: 7 MO
• Event Location: Outpatient Treatment Facility
• Date Report to Manufacturer: 09/12/2019
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 09/12/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Hospitalization
• Patient Age: 30 YR
• Patient Weight: 103