MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a 06 report with the FDA on 2000-02-25 for DEROYAL COVARDERM PLUS VAD DRESSING * 46-405 manufactured by Deroyal Industries, Inc..
[205346]
While removing the dressing, it causes the first layer of the skin to tear. This altered skin integrity.
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 1123071-2000-00006 |
| MDR Report Key | 265242 |
| Report Source | 06 |
| Date Received | 2000-02-25 |
| Date of Report | 2000-02-21 |
| Report Date | 2000-02-21 |
| Date Reported to FDA | 2000-02-21 |
| Date Mfgr Received | 2000-01-26 |
| Device Manufacturer Date | 1999-12-01 |
| Date Added to Maude | 2000-02-29 |
| 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 | 3 |
| Manufacturer Street | 200 DEBUSK LN |
| Manufacturer City | POWELL TN 37849 |
| Manufacturer Country | US |
| Manufacturer Postal | 37849 |
| Manufacturer Phone | 8659387828 |
| Manufacturer G1 | * |
| Manufacturer Street | * |
| Manufacturer City | * |
| Manufacturer Country | * |
| Single Use | 3 |
| Previous Use Code | 3 |
| Removal Correction Number | NA |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | DEROYAL COVARDERM PLUS VAD DRESSING |
| Generic Name | WOUND DRESSING |
| Product Code | MSA |
| Date Received | 2000-02-25 |
| Returned To Mfg | 2000-02-01 |
| Model Number | * |
| Catalog Number | 46-405 |
| Lot Number | 289980 |
| ID Number | * |
| Device Expiration Date | 2004-12-01 |
| Operator | HEALTH PROFESSIONAL |
| Device Availability | R |
| Device Age | 1 MO |
| Device Eval'ed by Mfgr | Y |
| Implant Flag | N |
| Date Removed | A |
| Device Sequence No | 1 |
| Device Event Key | 256782 |
| Manufacturer | DEROYAL INDUSTRIES, INC. |
| Manufacturer Address | 200 DEBUSK LANE POWELL TN 37849 US |
| Baseline Brand Name | DEROYAL COVADERM PLUS VAD DRESSING |
| Baseline Generic Name | WOUND DRESSING |
| Baseline Model No | NA |
| Baseline Catalog No | 46-405 |
| Baseline ID | NA |
| Baseline Device Family | WOUND DRESSING |
| Baseline Shelf Life Contained | Y |
| Baseline Shelf Life [Months] | 60 |
| Baseline PMA Flag | N |
| Baseline 510K PMN | Y |
| Premarket Notification | K910657 |
| Baseline Preamendment | N |
| Baseline Transitional | N |
| 510k Exempt | N |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 1. Other | 2000-02-25 |