MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a company representative,distri report with the FDA on 2019-09-20 for MERIT CUSTOM KIT K09-MST2294A manufactured by Merit Medical Systems, Inc..
| Report Number | 1721504-2019-00069 |
| MDR Report Key | 9098764 |
| Report Source | COMPANY REPRESENTATIVE,DISTRI |
| Date Received | 2019-09-20 |
| Date of Report | 2019-08-09 |
| Date of Event | 2019-07-23 |
| Date Mfgr Received | 2019-09-13 |
| Device Manufacturer Date | 2018-12-07 |
| Date Added to Maude | 2019-09-20 |
| 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 | 3 |
| Manufacturer Contact | MRS. KATIE SWENSON, CQE, CBA, CQPA |
| Manufacturer Street | 1600 W MERIT PARKWAY |
| Manufacturer City | SOUTH JORDAN 84095 |
| Manufacturer Country | US |
| Manufacturer Postal | 84095 |
| Manufacturer Phone | 8012081600 |
| Manufacturer G1 | MERIT MEDICAL SYSTEMS, INC. |
| Manufacturer Street | 1600 W MERIT PARKWAY |
| Manufacturer City | SOUTH JORDAN 84095 |
| Manufacturer Country | US |
| Manufacturer Postal Code | 84095 |
| Single Use | 3 |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | MERIT CUSTOM KIT |
| Generic Name | CUSTOM KIT |
| Product Code | OEZ |
| Date Received | 2019-09-20 |
| Returned To Mfg | 2019-09-09 |
| Catalog Number | K09-MST2294A |
| Lot Number | H1479449 |
| Device Availability | R |
| Device Eval'ed by Mfgr | Y |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | MERIT MEDICAL SYSTEMS, INC. |
| Manufacturer Address | 1600 W MERIT PARKWAY SOUTH JORDAN 84095 US 84095 |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 2019-09-20 |