MAUDE Adverse Event Report: CAREFUSION ALARIS® PUMP MODULE ADMINISTRATION SET; SET, ADMINISTRATION, INTRAVASCULAR

Model Number	10012283
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 affected product has been received and the evaluation is pending.A follow up report will be submitted once the evaluation is completed.The event reportedly occurred in the nicu; therefore it is presumed the patient was a neonate requested patient demographics however not provided.
Event or Problem Description
It was reported that the burette tubing with filter leaked tpn at an unspecified location.The event occurred in nicu there was no patient harm reported.Although requested there was no other event details provided.
Additional Manufacturer Narrative
The customer¿s report of the burette tubing with a filter leaked tpn was confirmed.The set was visually inspected for kinks, incomplete bonding engagements, holes/tears in the tubing or damages to the components.Yellowish colored liquid was observed in the set¿s burette and entire length of tubing.No abnormalities were observed on the set during visual inspection.Functional testing observed leaking out of both filter vents on the set¿s micron filter.Visual inspection observed no damage to the filter¿s membrane or housing.Although the root cause was not definitively determined, the probable cause of the observed filter vent leak was due to a clog/oversaturation of the filter and the time of use from which the fluid flow was restricted.The fluid then seeks the path of least resistance through the filter vent.
Event or Problem Description
It was reported that the burette tubing with filter leaked (tpn) at an unspecified location.The event occurred in the nicu.There was no patient harm reported.Although requested, there was no other patient or event details provided.

• Brand Name: ALARIS® PUMP MODULE ADMINISTRATION SET
• Common Device Name: SET, ADMINISTRATION, INTRAVASCULAR
• Manufacturer (Section D): CAREFUSION; 10020 pacific mesa blvd; san diego CA 92121 4386
• MDR Report Key: 9286679
• Report Number: 9616066-2019-03089
• Device Sequence Number: 13491586
• Product Code: FPA
• UDI-Device Identifier: 10885403233692
• UDI-Public: 10885403233692
• Combination Product (Y/N): N
• Initial Reporter State: TX
• Initial Reporter Country: US
• PMA/510(K) Number: K944320
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: health professional,other
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 10/10/2019

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: 03/02/2021
• Device Model Number: 10012283
• Device Catalogue Number: 10012283
• Device Lot Number: 18035035
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 10/22/2019
• Initial Date Received by Manufacturer: Not provided
• Supplement Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 11/06/2019
• Supplement Report FDA Received Date: 01/06/2020
• 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: (2) ORANGE CAPS TRIFUSE EXT SET, THERAPY DATE: UNK.