MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a 05,06 report with the FDA on 1999-07-01 for FILIFORM WITH STRAIGHT TIP 342104 manufactured by Rusch, Inc..
[141086]
It was reported that the device disconnected from the hub. Device was subsequently removed from the patient, with no further impact to the patient.
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 2429473-1999-00061 |
| MDR Report Key | 230159 |
| Report Source | 05,06 |
| Date Received | 1999-07-01 |
| Date of Report | 1999-06-28 |
| Date of Event | 1999-06-16 |
| Date Mfgr Received | 1999-06-16 |
| Date Added to Maude | 1999-07-07 |
| Event Key | 0 |
| Report Source Code | Manufacturer report |
| Manufacturer Link | Y |
| Number of Patients in Event | 0 |
| Adverse Event Flag | 3 |
| Product Problem Flag | 3 |
| Reprocessed and Reused Flag | 0 |
| Health Professional | 3 |
| Initial Report to FDA | 3 |
| Report to FDA | 3 |
| Event Location | 0 |
| Manufacturer Contact | KATRINA HALBIG |
| Manufacturer Street | 2450 MEADOWBROOK PARKWAY |
| Manufacturer City | DULUTH GA 30096 |
| Manufacturer Country | US |
| Manufacturer Postal | 30096 |
| Manufacturer Phone | 7706230816 |
| Manufacturer G1 | * |
| Manufacturer Street | * |
| Manufacturer City | * |
| Manufacturer Country | * |
| Single Use | 3 |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | FILIFORM WITH STRAIGHT TIP |
| Generic Name | URETHRAL FILIFORM |
| Product Code | FBW |
| Date Received | 1999-07-01 |
| Model Number | NA |
| Catalog Number | 342104 |
| Lot Number | UNK |
| ID Number | NA |
| Operator | HEALTH PROFESSIONAL |
| Device Availability | Y |
| Device Eval'ed by Mfgr | Y |
| Implant Flag | N |
| Date Removed | A |
| Device Sequence No | 1 |
| Device Event Key | 223215 |
| Manufacturer | RUSCH, INC. |
| Manufacturer Address | 2450 MEADOWBROOK PKWY. DULUTH GA 30096 US |
| Baseline Brand Name | OLIVE TIP FILIFORM |
| Baseline Generic Name | FILIFORM |
| Baseline Model No | NA |
| Baseline Catalog No | 342104 |
| Baseline ID | NA |
| Baseline Device Family | FILIFORM |
| Baseline Shelf Life Contained | * |
| Baseline Shelf Life [Months] | * |
| Baseline PMA Flag | N |
| Baseline 510K PMN | N |
| Baseline Preamendment | Y |
| Baseline Transitional | N |
| 510k Exempt | N |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 1. Required No Informationntervention | 1999-07-01 |