MAUDE Adverse Event Report: BARD ACCESS SYSTEMS SAFETY HUBER 20G X 0.75IN WITH NF VALVE; SET, ADMINISTRATION, INTRAVASCULAR

Model Number	N/A
Medical Device Problem Code	Fluid/Blood Leak (1250)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The manufacturer has received the sample and will evaluate.Results are expected soon.A lot history review (lhr) of recz0799 showed no other similar product complaint(s) from this lot number.
Event or Problem Description
It was reported the safety huber needle leaked.No other information was provided.
Additional Manufacturer Narrative
The following were reviewed as part of this investigation: patient severity, applicable previous investigation(s), sample analysis, applicable fmea documents, applicable manufacturing records, and labeling.Based on a review of this information, the following was concluded: the complaint of a leak in the infusion set was inconclusive since unused same lot samples were the only items returned for investigation.Twenty-five unopened safety huber needle sets from lot recz0799 were returned for investigation.No used device was returned for investigation.No damage was observed on the returned samples.A functional test revealed no leaks in any part of the infusion set.Since the affected devices were not returned for investigation, the complaint was inconclusive.A lot history review (lhr) of recz0799 showed no other similar product complaint(s) from this lot number.
Event or Problem Description
It was reported the safety huber needle leaked.No other information was provided.

• Brand Name: SAFETY HUBER 20G X 0.75IN WITH NF VALVE
• Common Device Name: SET, ADMINISTRATION, INTRAVASCULAR
• Manufacturer (Section D): BARD ACCESS SYSTEMS; 605 n. 5600 w.; salt lake city UT 84116
• MDR Report Key: 9225329
• Report Number: 3006260740-2019-03293
• Device Sequence Number: 127368
• Product Code: FPA
• UDI-Device Identifier: 00801741044922
• UDI-Public: (01)00801741044922
• Combination Product (Y/N): N
• Initial Reporter State: PA
• Initial Reporter Country: US
• PMA/510(K) Number: K071846
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: distributor,other
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 11/27/2019

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: N/A
• Device Catalogue Number: 585112
• Device Lot Number: RECZ0799
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 10/14/2019
• Event Location: Hospital
• Initial Date Received by Manufacturer: 10/01/2019
• Supplement Date Received by Manufacturer: 11/20/2019
• Initial Report FDA Received Date: 10/23/2019
• Supplement Report FDA Received Date: 11/27/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1