CTM ACCLM ULNA W HOLES STD RT 172246989

MAUDE Adverse Event Report

MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a 05,07,08 report with the FDA on 2004-01-09 for CTM ACCLM ULNA W HOLES STD RT 172246989 manufactured by Depuy Orthopaedics, Inc..

Event Text Entries

[340682] Product was labeled incorrectly. Surgery was delayed one hour and the pt has a broken bone.
Patient Sequence No: 1, Text Type: D, B5


MAUDE Entry Details

Report Number1818910-2004-00017
MDR Report Key505777
Report Source05,07,08
Date Received2004-01-09
Date of Report2003-12-10
Date of Event2003-12-10
Date Facility Aware2003-12-10
Report Date2003-12-10
Date Mfgr Received2003-12-10
Device Manufacturer Date2003-11-01
Date Added to Maude2004-01-13
Event Key0
Report Source CodeManufacturer report
Manufacturer LinkY
Number of Patients in Event0
Adverse Event Flag3
Product Problem Flag3
Reprocessed and Reused Flag3
Health Professional3
Initial Report to FDA3
Report to FDA3
Event Location3
Manufacturer ContactHANS KUSSEROW, MGR
Manufacturer Street700 ORTHOPAEDIC DR
Manufacturer CityWARSAW IN 465810988
Manufacturer CountryUS
Manufacturer Postal465810988
Manufacturer Phone5743727416
Manufacturer G1DEPUY ORTHOPAEDICS, INC.
Manufacturer Street700 ORTHOPAEDIC DR
Manufacturer CityWARSAW IN 46581098
Manufacturer CountryUS
Manufacturer Postal Code46581 0988
Single Use3
Remedial ActionOT
Previous Use Code3
Removal Correction NumberNA
Event Type3
Type of Report3

Device Details

Brand NameCTM ACCLM ULNA W HOLES STD RT
Generic NameEXTREMITIES
Product CodeKWJ
Date Received2004-01-09
Model NumberNA
Catalog Number172246989
Lot NumberX5BFB1000
ID NumberNA
OperatorHEALTH PROFESSIONAL
Device AvailabilityY
Device AgeUNKNOWN
Device Eval'ed by MfgrR
Implant FlagY
Date RemovedA
Device Sequence No1
Device Event Key494644
ManufacturerDEPUY ORTHOPAEDICS, INC.
Manufacturer Address700 ORTHOPAEDIC DR. WARSAW IN 465810988 US
Baseline Brand NameCTM ACCLM ULNA W HOLES STD RT
Baseline Generic NameCUSTOMER ELBOW
Baseline Model NoNA
Baseline Catalog No172246989
Baseline IDNA
Baseline Device FamilyCUSTOM ACCLAIM ULNA
Baseline Shelf Life ContainedN
Baseline Shelf Life [Months]NA
Baseline PMA FlagN
Baseline 510K PMNN
Baseline PreamendmentN
Baseline TransitionalN
510k ExemptY


Patients

Patient NumberTreatmentOutcomeDate
101. Required No Informationntervention 2004-01-09

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