FDA Adverse Event Malfunction Summary report: N

BD Q-SYTE¿ LUER ACCESS SPLIT-SEPTUM STAND-ALONE DEVICE

MDR report key: 14959974 · Received July 8, 2022

Report

Report Number
2243072-2022-00920
Event Type
Malfunction
Date Received
July 8, 2022
Date of Event
June 9, 2022
Report Date
August 30, 2022
Manufacturer
BD INFUSION THERAPY SYSTEMS INC. S.A. DE C.V.
Product Code
FPA
UDI-DI
00382903851003
PMA / PMN Number
K013621
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
OH, US
Reporter Occupation
OTHER HEALTH CARE PROFESSIONAL
Health Professional
Yes

Narratives

Additional Manufacturer Narrative · 0

UNKNOWN MANUFACTURER: THERE ARE MULTIPLE BD LOCATIONS WHERE THIS UNSPECIFIED BD DEVICE MAY HAVE BEEN MANUFACTURED. A CATALOG AND LOT NUMBER COULD NOT BE CONFIRMED FOR THIS INCIDENT AND WITHOUT THIS INFORMATION WE ARE UNABLE TO DETERMINE WHERE THE DEVICE WAS MANUFACTURED. THEREFORE, BD CORPORATE HEADQUARTERS IN (B)(4) HAS BEEN LISTED IN THE (B)(4) FDA REGISTRATION NUMBER HAS BEEN USED FOR THE MANUFACTURE REPORT NUMBER. DATE OF EVENT: UNKNOWN. THE DATE RECEIVED BY MANUFACTURER HAS BEEN USED FOR THIS FIELD. MEDICAL DEVICE EXPIRATION DATE: UNKNOWN. A DEVICE EVALUATION IS ANTICIPATED, BUT HAS NOT YET BEGUN. UPON COMPLETION OF THE INVESTIGATION, A SUPPLEMENTAL REPORT WILL BE FILED. DEVICE MANUFACTURE DATE: UNKNOWN.

Additional Manufacturer Narrative · 0

THE FOLLOWING FIELDS WERE UPDATED DUE TO ADDITIONAL INFORMATION: B.5. DESCRIBE EVENT OR PROBLEM: IT WAS REPORTED THAT WHILE USING A BD Q-SYTE¿ STAND-ALONE DEVICE, THE DEVICE WAS CLOGGED. THE FOLLOWING INFORMATION WAS PROVIDED BY THE INITIAL REPORTER: THE Q-SYTE'S WILL NOT OPEN WHEN ACCESSED. D.1. MEDICAL DEVICE BRAND NAME: BD Q-SYTE¿ LUER ACCESS SPLIT-SEPTUM STAND-ALONE DEVICE; D.3. MEDICAL DEVICE MANUFACTURER: BD INFUSION THERAPY SYSTEMS INC. S.A. DE C.V.; D.4. MEDICAL DEVICE CATALOG #: 385100; D.4. UNIQUE IDENTIFIER (UDI) #: (B)(4); G.1. MANUFACTURING LOCATION: BD INFUSION THERAPY SYSTEMS INC. S.A. DE C.V.; G.5. PMA / 510(K)#: K013621. H.6. INVESTIGATION SUMMARY: OUR QUALITY ENGINEER INSPECTED THE SAMPLES AND PHOTOGRAPH FOR EVALUATION. BD RECEIVED 4 Q-SYTE ASSEMBLIES AND ONE PHOTOGRAPH. A MICROSCOPIC INSPECTION OF THE SEPTUM WAS PERFORMED, AND IT WAS FOUND THAT THE BOTTOM DISKS AND ALL RETURNED UNITS DID NOT HAVE SLITS IN THEM. THE REPORTED ISSUE WAS CONFIRMED. THIS WAS PHYSICAL EVIDENCE TO CONFIRM AND SUPPORT A MANUFACTURING PROCESS RELATED ISSUE FOR THE REPORTED DEFECT. ONE OF THE DEVICES HAD AN INCOMPLETE WELDING LEADING TO SEPARATION OF THE MALE FROM FEMALES LUERS. THE SEPTA ARE SLIT DURING THE MANUFACTURING PROCESS. IF A SEPTUM IS NOT SLIT IT MAY BE A RESULT OF A BROKEN/MISSING BLADE, OR MIXED PRODUCT OF NON-SLIT SEPTUM WITH SLIT SEPTUM. THERE IS A 100% INSPECTION DURING THE LUBE STATION THAT CHECKS FOR THE PRESENCE OF A SLIT. IT IS POSSIBLE THAT A NO SLIT WOULD PASS IF THE STATION ACTUATION FORCE IS SET TOO HIGH. OPERATORS ALSO INSPECT FOR NO SLIT PER THE QUALITY PLAN. DURING MANUFACTURING, THE INCOMPLETE WELDING MAY OCCUR DUE TO IMPROPER SETUP. OPERATORS PERFORMED INSPECTION AT SET UP WELD FOR PART ALIGNMENT. A DEVICE HISTORY RECORD REVIEW SHOWED NO NON-CONFORMANCES ASSOCIATED WITH THIS ISSUE DURING THE PRODUCTION OF THIS BATCH. H3 OTHER TEXT : SEE H.10.

Description of Event or Problem · 0

IT WAS REPORTED UNSPECIFIED BD Q-SYTE¿ STAND-ALONE DEVICE WAS CLOGGED DURING USE. THE FOLLOWING INFORMATION WAS PROVIDED BY THE INITIAL REPORTER: "I SENT THIS IN BECAUSE HOPE WHEN A CUSTOMER ORDERS NEXIVA OR Q-SYTE STAND ALONES THEY ARE NOT ¿CLOGGED¿ LIKE THESE ARE AND CANNOT USE."

Description of Event or Problem · 0

IT WAS REPORTED THAT WHILE USING A BD Q-SYTE¿ STAND-ALONE DEVICE, THE DEVICE WAS CLOGGED. THE FOLLOWING INFORMATION WAS PROVIDED BY THE INITIAL REPORTER: THE Q-SYTE'S WILL NOT OPEN WHEN ACCESSED.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1986575 BD Q-SYTE¿ LUER ACCESS SPLIT-SEPTUM STAND-ALONE DEVICE INTRAVASCULAR ADMINISTRATION SET FPA BD INFUSION THERAPY SYSTEMS INC. S.A. DE C.V. UNKNOWN 00382903851003

Patients

Seq Age Sex Outcome Treatment
1 Unknown