FDA.reportPublic FDA data

MAUDE MDR 1691034

MDR report key
1691034
Report number
MW5015929
Event key
0
Event type
3
Date of event
2010-04-28
Date received
2010-05-11
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
500
Health professional
3
Initial report to FDA
3
Event location
0

Manufacturer Contact#

Report source
P
Manufacturer link flag
N

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1OXYGEN FLOWMETERCHEMTRONCAXVARIOUS
2QUICK CONNECT ADAPTERNPT MALE-OXYGENCHEMTRONBYX12-01-1000
3QUICK CONNECT ADAPTERDISS MALE-OXYGENCHEMTRONBYX12-01-3000
4QUICK CONNECT ADAPTERAIRCHEMTRONBYX12-01-1100
5QUICK CONNECT ADAPTERAIRCHEMTRONBYX12-01-3100

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12010-05-110

Event Narratives#

D

Patient 1

FLOWMETER SEPARATED FROM WALL PLATE (OXYGEN SUPPLY), PROPELLED FROM WALL NARROWLY MISSING PT.