MAUDE Adverse Event Report: BECTON, DICKINSON & CO. (BROKEN BOW) BD VACUTAINER® SODIUM HEPARINN (NH) 33 USP = 33 IU BLOOD COLLECTION TUBES; BLOOD SPECIMEN COLLECTION DEVICE

Model Number	367671
Medical Device Problem Code	Leak/Splash (1354)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	11/04/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Date of event: unknown.The date received by manufacturer has been used for this field.A device evaluation is anticipated, but has not yet begun.Upon completion of the investigation and/or device history review, a supplemental report will be filed.
Event or Problem Description
Material no.367671, batch no.9095735.It was reported that after use of the bd vacutainer® sodium heparinn (nh) 33 usp = 33 iu blood collection tubes the stoppers have been coming off of tubes.The following information was provided by the initial reporter: there is an issues with the lids coming off tubes causing the loss of samples.
Additional Manufacturer Narrative
A.2.Age at time of event: 35; a.2 date of birth: (b)(6); a.3.Sex: male h3 other text : see section h.10.
Event or Problem Description
Material no.367671; batch no.9095735.It was reported that after use of the bd vacutainer® sodium heparinn (nh) 33 usp = 33 iu blood collection tubes the stoppers have been coming off of tubes.The following information was provided by the initial reporter: there is an issues with the lids coming off tubes causing the loss of samples.
Additional Manufacturer Narrative
H.6.Investigation: bd had not received samples, but photos were provided by the customer facility for investigation.The photos were evaluated and the customer's indicated failure mode for stopper creepout with the incident lot was observed.A review of the device history record was completed for the incident lot and, based on this review, all product specifications and requirements for lot release were met; there were no related quality non-conformances during manufacturing of the product.
Event or Problem Description
Material no.367671.Batch no.9095735.It was reported that after use of the bd vacutainer® sodium heparin (nh) 33 usp = 33 iu blood collection tubes the stoppers have been coming off of tubes.The following information was provided by the initial reporter: there is an issues with the lids coming off tubes causing the loss of samples.

• Brand Name: BD VACUTAINER® SODIUM HEPARINN (NH) 33 USP = 33 IU BLOOD COLLECTION TUBES
• Common Device Name: BLOOD SPECIMEN COLLECTION DEVICE
• Manufacturer (Section D): BECTON, DICKINSON & CO. (BROKEN BOW); 150 south 1st avenue; broken bow NE 68822
• MDR Report Key: 9355216
• Report Number: 1917413-2019-02374
• Device Sequence Number: 18969364
• Product Code: JKA
• UDI-Device Identifier: 50382903676717
• UDI-Public: 50382903676717
• Combination Product (Y/N): N
• Initial Reporter State: IN
• Initial Reporter Country: US
• PMA/510(K) Number: K945952
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: other,user facility
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup,Followup
• Report Date (Section B): 02/03/2020

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?: Yes
• Operator of Device: Other
• Device Expiration Date: 10/31/2020
• Device Model Number: 367671
• Device Catalogue Number: 367671
• Device Lot Number: 9095735
• Initial Date Received by Manufacturer: 11/04/2019
• Supplement Date Received by Manufacturer: 11/04/2019; 11/04/2019
• Initial Report FDA Received Date: 11/21/2019
• Supplement Report FDA Received Date: 11/25/2019; 02/03/2020
• 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: Other
• Patient Age: 35 YR