MAUDE Adverse Event Report: BARD ACCESS SYSTEMS STATLOCK IV SELECT MACROBORE 6IN IV START KIT 50 BOX; STAND, INFUSION

Model Number	N/A
Medical Device Problem Code	Detachment of Device or Device Component (2907)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The device has not been returned to the manufacturer for evaluation.A lot history review (lhr) of judz0180 showed three other similar product complaint(s) from this lot number.The complaints for this lot number (judz0180) have been reported from the same facility.
Event or Problem Description
It was reported that the statlock fell off of four different patients, causing blood to leak.No other information was provided.This report addresses the second of four devices.

• Brand Name: STATLOCK IV SELECT MACROBORE 6IN IV START KIT 50 BOX
• Common Device Name: STAND, INFUSION
• Manufacturer (Section D): BARD ACCESS SYSTEMS; 605 n. 5600 w.; salt lake city UT 84116
• MDR Report Key: 9880369
• Report Number: 3006260740-2020-01051
• Device Sequence Number: 3041694
• Product Code: FPA
• UDI-Device Identifier: 00801741082665
• UDI-Public: (01)00801741082665
• Combination Product (Y/N): N
• Initial Reporter State: CO
• Initial Reporter Country: US
• PMA/510(K) Number: K942931
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: user facility
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 03/25/2020

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: Health Professional
• Device Expiration Date: 03/28/2022
• Device Model Number: N/A
• Device Catalogue Number: IVK0177
• Device Lot Number: JUDZ0180
• Was Device Available for Evaluation?: No
• Event Location: Hospital
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/04/2020
• Initial Report FDA Received Date: 03/25/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1