MAUDE MDR 25000

MDR report key
25000
Report number
25000
Event key
0
Event type
3
Date of event
1995-05-04
Date received
1995-07-25
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
0
Health professional
0
Initial report to FDA
0
Event location
3

Manufacturer Contact#

Report source
U
Manufacturer link flag
N

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1ULTRA-R BARIUMULTRA-R BARIUME-Z-EM CO.FCEUR4008B, 4008A**

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
11995-07-2501. D

Event Narratives#

D

Patient 1

THEPT WAS SCHEDULED FOR A UGI AND SMALL BOWEL SERIES ON 5/4/95. HE HAD A HISTORY OF REFLUX, COPD, PNEUMONIA, TB-MAI IN 1994. DURING THE UGI HE HAD A SMALL AMOUNT OF COUGHING, BUT DID NOT APPEAR TO HAVE ASPIRATED THE BARIUM. SUBSEQUENT ABDOMINAL FILMS FOR THE SMALL BOWEL SERIES SHOWED THERE WAS A MEDIUM AMOUNT OF BARIUM IN THE BRONCHIAL TREE, LOWER LOBES, APPARENTLY DUE TO ASPIRATION. THE PT WAS MONITORED FOR 2 AND 1/2 HOURS FOLLOWING THE PROCEDURES AND HAD NO DISTRESS OR CHANGE IN VITAL SIGNS. THE PT DEVELOPED PNEUMONIA/ARDS AND SUBSEQUENTLY DIED ON 5/12/95.INVALID DATA - REGARDING SINGLE USE LABELING OF DEVICE. PATIENT MEDICAL STATUS PRIOR TO EVENT: UNKNOWN. THERE WAS NOT MULTIPLE PATIENT INVOLVEMENT.INVALID DATA - ON DEVICE SERVICE/MAINTENANCE. NO DATA - REGARDING DATE LAST SERVICED. SERVICE PROVIDED BY: INVALID DATA. INVALID DATA - SERVICE RECORDS AVAILABILITY.INVALID DATA - REGARDING WHETHER EVENT PRESENTS IMMINENT HAZARD. INVALID DATA - WHETHER DEVICE USED AS LABELED/INTENDED.INVALID DATA - REGARDING EVALUATION BY USER AFTER EVENT. METHOD OF EVALUATION: INVALID DATA. RESULTS OF EVALUATION: INVALID DATA. CONCLUSION: INVALID DATA. CERTAINTY OF DEVICE AS CAUSE OF OR CONTRIBUTOR TO EVENT: INVALID DATA. CORRECTIVE ACTIONS: NO DATA. INVALID DATA - ON DEVICE DESTROYED/DISPOSED OF STATUS.