MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a consumer report with the FDA on 2020-01-24 for POISE IMPRESSA : PESSARY, VAGINAL : HHW SIZE 3 manufactured by K-c Afc Manufacturing, S. De R.l. De C.v.
[176278169]
A manufacturer lot code was not provided. With no means to ascertain the manufacturer/asset line and day of production, no further investigation on documents and supporting records can be performed.
Patient Sequence No: 1, Text Type: N, H10
[176278171]
Consumer reported the petals from the pessary insertion tube were open and one of the petals was sharp and caused lacerations and bleeding upon insertion. She did not seek medical attention and has recovered.
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 3011109575-2020-00487 |
| MDR Report Key | 9628353 |
| Report Source | CONSUMER |
| Date Received | 2020-01-24 |
| Date of Report | 2020-01-24 |
| Date of Event | 2017-01-05 |
| Date Mfgr Received | 2017-01-06 |
| Date Added to Maude | 2020-01-24 |
| 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. EMILY ARNOULD, RN BSN |
| Manufacturer Street | 2100 WINCHESTER RD |
| Manufacturer City | NEENAH WI 54956 |
| Manufacturer Country | US |
| Manufacturer Postal | 54956 |
| Manufacturer Phone | 9207213128 |
| Manufacturer G1 | K-C AFC MANUFACTURING, S. DE R.L. DE C.V |
| Manufacturer Street | CALZADA INDUSTRIAL DE LAS MAQUILADORAS #87 NUEVO NOGALES |
| Manufacturer City | NOGALES, SONORA MEXICO 84094 |
| Manufacturer Country | MX |
| Manufacturer Postal Code | 84094 |
| Single Use | 3 |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | POISE IMPRESSA : PESSARY, VAGINAL : HHW |
| Generic Name | PESSARY, VAGINAL |
| Product Code | HHW |
| Date Received | 2020-01-24 |
| Model Number | SIZE 3 |
| Operator | LAY USER/PATIENT |
| Device Availability | N |
| Device Eval'ed by Mfgr | R |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | K-C AFC MANUFACTURING, S. DE R.L. DE C.V |
| Manufacturer Address | CALZADA INDUSTRIAL DE LAS MAQUILADORAS #87 NUEVO NOGALES NOGALES, SONORA MEXICO 84094 MX 84094 |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 2020-01-24 |