N
Patient 1
MAUDE MDR 5690269
- MDR report key
- 5690269
- Report number
- 1419185-2016-00007
- Event key
- 0
- Event type
- 3
- Date of event
- 2015-03-27
- Date received
- 2016-05-31
- Adverse event
- 3
- Product problem
- 3
- Patients in event
- 0
- Reporter occupation
- 401
- Health professional
- 3
- Initial report to FDA
- 3
- Event location
- 3
Manufacturer Contact#
- Contact
- MS JESSICA BARRILE
- Address
- 1111 LAKESIDE DR GURNEE IL 60031 US
- Phone
- 847-847-8478
- Report source
- M
- Manufacturer link flag
- Y
Devices#
| Seq | Brand | Generic | Manufacturer | Product code | Model | Catalog | Lot | PMA | 510(k) | Implant | Evaluated | Availability |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | PUSH TO SET INTERMITTANT SUCTION REGULATOR | PTS ISU | OHIO MEDICAL | KDP | 1251 | 8707-1251-905 | ISU087152 | Y | R |
Patients#
| Sequence | Received | Treatment | Outcome |
|---|---|---|---|
| 1 | 2016-05-31 | 0 |
Event Narratives#
D
Patient 1
A USER FACILITY REPORTED TO US THAT THE DEVICE "HAS INTERNAL CAP ISSUES" ON (B)(6) 2015. THERE WAS NO PATIENT INVOLVEMENT, AND THE INCIDENT DID NOT RESULT IN A DELAY OF TREATMENT. THE DEVICE WAS EVALUATED ON 03/27/2015 AND IT WAS NOTED THAT THE DEVICE HAD A DAMAGED DIAPHRAGM. OUR RISK DOCUMENT CLASSIFIES THE SEVERITY OF A DAMAGED DIAPHRAGM AS "POTENTIALLY REQUIRING MEDICAL INTERVENTION TO PREVENT PERMANENT IMPAIRMENT OF A BODY FUNCTION OR PERMANENT DAMAGE TO A BODY STRUCTURE". WE ARE OBTAINING FURTHER CLINICAL EVALUATION OF THE RISK OF THIS FAILURE AND WILL PROVIDE FOLLOW UP TO THIS REPORT ONCE OBTAINED.
N
Patient 1
CLINICAL ASSESSMENT OF THE FAILURE MODE "DAMAGED DIAPHRAGM" HAS BEEN OBTAINED AND IT HAS BEEN DETERMINED THAT THIS OCCURRENCE DOES NOT REPRESENT A REPORTABLE MALFUNCTION DUE TO NO EVIDENCE EXISTING TO REASONABLY SUGGEST THAT THE MALFUNCTION WOULD BE LIKELY TO CAUSE OR CONTRIBUTE TO DEATH OR SERIOUS INJURY IF IT WERE TO RECUR. (B)(4).
D
Patient 1
CLINICAL ASSESSMENT OF THE FAILURE MODE "DAMAGED DIAPHRAGM" HAS BEEN OBTAINED AND IT HAS BEEN DETERMINED THAT THIS OCCURRENCE DOES NOT REPRESENT A REPORTABLE MALFUNCTION DUE TO NO EVIDENCE EXISTING TO REASONABLY SUGGEST THAT THE MALFUNCTION WOULD BE LIKELY TO CAUSE OR CONTRIBUTE TO DEATH OR SERIOUS INJURY IF IT WERE TO RECUR.