MAUDE Adverse Event Report: COVIDIEN MAGELLAN 3ML SFTY COMBO 25X5/8; NEEDLE, HYPODERMIC, SINGLE LUMEN

Model Number	8881833558
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	10/11/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The incident sample has been requested but to date has not been received for evaluation.If the sample is received, or if additional information pertinent to the incident is obtained a follow-up report will be submitted.As part of our manufacturing process, all device history records are reviewed and approved by quality, prior to release of product.
Event or Problem Description
The customer reported that the needle was defective.Based on the photos provided by the customer, the hub of the needle is completely cracked into two pieces.
Additional Manufacturer Narrative
Additional information: the device history record (dhr) for the reported lot number shows no issues were found in visual and physical samples inspected from the lot.The lot met all defined acceptance requirements and was released.There were no samples submitted with this complaint, however, pictures of the reported condition that were sent from the customer were analyzed.The needle hub looked to be fractured into 2 pieces.The reported condition is confirmed based on the customer provided images.The exact root cause of the reported condition could not be determined without a physical sample to examine.A specific root cause could not be determined without the physical sample to examine.There was no indication of a systemic issue with the process or production.Based on available information, no corrective or preventative action (capa) is required at this time.This information will be utilized for trending purposes to determine the need for corrective actions.

• Brand Name: MAGELLAN 3ML SFTY COMBO 25X5/8
• Common Device Name: NEEDLE, HYPODERMIC, SINGLE LUMEN
• Manufacturer (Section D): COVIDIEN; 2010 east international speedw; deland FL 32724
• MDR Report Key: 9253882
• Report Number: 1017768-2019-00716
• Device Sequence Number: 13960730
• Product Code: FMI
• UDI-Device Identifier: 10884521005846
• UDI-Public: 10884521005846
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: distributor,user facility
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 01/28/2020

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: 8881833558
• Device Catalogue Number: 8881833558
• Device Lot Number: 907744
• Was Device Available for Evaluation?: Yes
• Initial Date Received by Manufacturer: 10/11/2019
• Supplement Date Received by Manufacturer: 10/11/2019
• Initial Report FDA Received Date: 10/29/2019
• Supplement Report FDA Received Date: 01/28/2020
• Patient Sequence Number: 1