MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a 06 report with the FDA on 2003-01-24 for BLAKEMORE TUBE 204803180 manufactured by Willy Rusch Ag.
[18446253]
Hole in large balloon.
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 9610520-2003-00014 |
| MDR Report Key | 439875 |
| Report Source | 06 |
| Date Received | 2003-01-24 |
| Date of Report | 2003-01-24 |
| Date Mfgr Received | 2003-01-09 |
| Date Added to Maude | 2003-01-30 |
| 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 | 3 |
| Health Professional | 3 |
| Initial Report to FDA | 3 |
| Report to FDA | 3 |
| Event Location | 0 |
| 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 | BLAKEMORE TUBE |
| Generic Name | ESOPHAGEAL |
| Product Code | KDH |
| Date Received | 2003-01-24 |
| Model Number | NA |
| Catalog Number | 204803180 |
| Lot Number | 229222 |
| 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 | 428811 |
| Manufacturer | WILLY RUSCH AG |
| Manufacturer Address | WILLY-RUSCH STRASSE 4-10 KERNEN I.R. GM 71394 |
| Baseline Brand Name | BLAKEMORE TUBE |
| Baseline Model No | NA |
| Baseline Catalog No | 204803180 |
| Baseline ID | NA |
| Baseline Shelf Life Contained | * |
| Baseline Shelf Life [Months] | 60 |
| Baseline PMA Flag | N |
| Baseline 510K PMN | N |
| Baseline Preamendment | Y |
| Baseline Transitional | N |
| 510k Exempt | N |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 2003-01-24 |