MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a 05,06,07 report with the FDA on 2000-10-17 for PERCUPUMP TOUCHSCREEN INJECTOR SYSTEM W/ EDA 7805 manufactured by E-z-em, Inc..
[200283]
Pt undergoing chest and abdominal ct. Iv site was placed in right antecubital area. Iv was 20 gauge. Test dose of contrast was injected without problems detected by staff or pt. The injection was then started at 1. 8cc/sec. After 80 cc injected, iv contrast began to spray on pt's face. Injection stopped. Extravasation noticed. Arm elevated and heat applied to area. Plain x-ray taken. Pt referred to primary physician office. Injector detector patch was in place at time of extravasation. Injector did not stop injecting contrast.
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 2432460-2000-00034 |
| MDR Report Key | 301341 |
| Report Source | 05,06,07 |
| Date Received | 2000-10-17 |
| Date of Report | 2000-10-17 |
| Date of Event | 2000-08-21 |
| Date Facility Aware | 2000-08-21 |
| Report Date | 2000-10-17 |
| Date Reported to Mfgr | 2000-10-17 |
| Date Mfgr Received | 2000-10-17 |
| Date Added to Maude | 2000-10-25 |
| 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 Contact | PETER APRILE, R.PH. |
| Manufacturer Street | 717 MAIN ST |
| Manufacturer City | WESTBURY NY 11590 |
| Manufacturer Country | US |
| Manufacturer Postal | 11590 |
| Manufacturer Phone | 8005444624 |
| Manufacturer G1 | * |
| Manufacturer Street | * |
| Manufacturer City | * |
| Manufacturer Country | * |
| Single Use | 3 |
| Remedial Action | PM |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | PERCUPUMP TOUCHSCREEN INJECTOR SYSTEM W/ EDA |
| Generic Name | CT INJECTOR W/ EXTRAVASATION ACCESSORY |
| Product Code | FIH |
| Date Received | 2000-10-17 |
| Model Number | NA |
| Catalog Number | 7805 |
| Lot Number | NA |
| ID Number | NA |
| Operator | HEALTH PROFESSIONAL |
| Device Availability | N |
| Device Age | UNKNOWN |
| Device Eval'ed by Mfgr | R |
| Implant Flag | N |
| Date Removed | A |
| Device Sequence No | 1 |
| Device Event Key | 291649 |
| Manufacturer | E-Z-EM, INC. |
| Manufacturer Address | 750 SUMMA AVE. WESTBURY NY 11590 US |
| Baseline Brand Name | PERCUPUMP TOUCHSCREEN INJECTOR W/EDA |
| Baseline Generic Name | CT INJECTOR SYSTEM |
| Baseline Model No | NA |
| Baseline Catalog No | 7805 |
| Baseline ID | NA |
| Baseline Device Family | PERCUPUMP INJECTOR SYSTEM |
| Baseline Shelf Life [Months] | NA |
| Baseline PMA Flag | N |
| Baseline 510K PMN | Y |
| Premarket Notification | K961845 |
| Baseline Preamendment | N |
| Baseline Transitional | N |
| 510k Exempt | N |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 1. Other | 2000-10-17 |