BEUDAMED
    FDA Adverse Event Injury Summary report: N

    FLUIDSHIELD* PORTED N95 PARTICULATE FILTER RESPIRATOR AND SURGICAL MASK

    MDR report key: 10024203 · Received May 5, 2020

    Report

    Report Number
    9616096-2020-00005
    Event Type
    Injury
    Date Received
    May 5, 2020
    Date of Event
    April 15, 2020
    Report Date
    June 10, 2020
    Manufacturer
    OWENS & MINOR HALYARD
    Product Code
    MSH
    UDI-DI
    30680651468278
    PMA / PMN Number
    K974068
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    NY, US
    Reporter Occupation
    NURSE

    Narratives

    Additional Manufacturer Narrative · 0

    THE ACTUAL COMPLAINT PRODUCT SAMPLE WAS NOT RETURNED FOR EVALUATION. A REVIEW OF THE DEVICE HISTORY RECORD IS NOT POSSIBLE AS NO LOT NUMBER WAS PROVIDED. ROOT CAUSE COULD NOT BE DETERMINED. ALL INFORMATION REASONABLY KNOWN AS OF 30JUN2020 HAS BEEN INCLUDED IN THIS HEALTH AUTHORITY REPORT. SHOULD ADDITIONAL INFORMATION BE OBTAINED, A FOLLOW-UP HEALTH AUTHORITY REPORT WILL BE PROVIDED. THE INFORMATION PROVIDED BY O&M HALYARD, INC. REPRESENTS ALL OF THE KNOWN INFORMATION AT THIS TIME. DESPITE GOOD FAITH EFFORTS TO OBTAIN ADDITIONAL INFORMATION, THE COMPLAINANT / REPORTER WAS UNABLE OR UNWILLING TO PROVIDE ANY FURTHER PATIENT, PRODUCT, OR PROCEDURAL DETAILS TO O&M HALYARD, INC. O&M HALYARD, INC. HAS NO INDEPENDENT KNOWLEDGE OF THE EVENT REPORTED BUT IS RELAYING THE INFORMATION THAT WAS PROVIDED BY THE USER FACILITY WHERE THE INCIDENT OCCURRED. THIS PRODUCT INCIDENT IS DOCUMENTED IN THE HALYARD HEALTH COMPLAINT DATABASE AND IDENTIFIED AS COMPLAINT (B)(4). THIS INFORMATION IS SUBMITTED PURSUANT TO 21CFR803, IN COMPLIANCE WITH THE MEDICAL DEVICE REPORTING REQUIREMENT AND SHOULD NOT BE CONSIDERED TO BE AN ADMISSION THAT A HALYARD HEALTH PRODUCT IS DEFECTIVE OR CAUSED SERIOUS INJURY.

    Additional Manufacturer Narrative · 1

    THE ACTUAL COMPLAINT PRODUCT SAMPLE IS NOT AVAILABLE FOR EVALUATION. A REVIEW OF THE DEVICE HISTORY RECORD IS NOT POSSIBLE AS NO LOT NUMBER WAS PROVIDED. ALL INFORMATION REASONABLY KNOWN AS OF 04MAY2020 HAS BEEN INCLUDED IN THIS HEALTH AUTHORITY REPORT. SHOULD ADDITIONAL INFORMATION BE OBTAINED, A FOLLOW-UP HEALTH AUTHORITY REPORT WILL BE PROVIDED. THE INFORMATION PROVIDED BY O&M HALYARD, INC. REPRESENTS ALL OF THE KNOWN INFORMATION AT THIS TIME. DESPITE GOOD FAITH EFFORTS TO OBTAIN ADDITIONAL INFORMATION, THE COMPLAINANT / REPORTER WAS UNABLE OR UNWILLING TO PROVIDE ANY FURTHER PATIENT, PRODUCT, OR PROCEDURAL DETAILS TO O&M HALYARD, INC. O&M HALYARD, INC. HAS NO INDEPENDENT KNOWLEDGE OF THE EVENT REPORTED BUT IS RELAYING THE INFORMATION THAT WAS PROVIDED BY THE USER FACILITY WHERE THE INCIDENT OCCURRED. THIS PRODUCT INCIDENT IS DOCUMENTED IN THE HALYARD HEALTH COMPLAINT DATABASE AND IDENTIFIED AS COMPLAINT (B)(4). THIS INFORMATION IS SUBMITTED PURSUANT TO 21CFR803, IN COMPLIANCE WITH THE MEDICAL DEVICE REPORTING REQUIREMENT AND SHOULD NOT BE CONSIDERED TO BE AN ADMISSION THAT A HALYARD HEALTH PRODUCT IS DEFECTIVE OR CAUSED SERIOUS INJURY. OTHER TEXT : DEVICE NOT RETURNED

    Description of Event or Problem · 1

    IT WAS REPORTED BY THE CUSTOMER WHO STATED THAT SHE EXPERIENCED A SKIN RASH ON HER FACE AFTER WEARING THE MASK FOR A 12 HOUR PERIOD. SHE WAS SEEN BY EMPLOYEE HEALTH IN THE EMERGENCY ROOM AND HAD A TELEMEDICINE CONSULT WITH A PHYSICIAN AS A FOLLOW UP. THE CUSTOMER STATED SHE WAS PRESCRIBED A TOPICAL STEROID CREAM. THE ISSUE WAS RESOLVED BY SWITCHING TO A DIFFERENT MASK. THE CUSTOMER STATES THAT SHE HAS A HISTORY OF EXISTING ALLERGIES AND CARRIES AN EPIPEN. THE CUSTOMER STATED SHE EXPERIENCED SHORTNESS OF BREATH WEARING "A MASK" BUT SHE STATES SHE IS UNSURE IF THE SOB OCCURRED WITH A HALYARD MASK. NO ADDITIONAL INFORMATION WAS PROVIDED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    489319 FLUIDSHIELD* PORTED N95 PARTICULATE FILTER RESPIRATOR AND SURGICAL MASK ICP FACIAL PROTECTION PRODUCTS MSH OWENS & MINOR HALYARD 46827 UNKNOWN 30680651468278

    Patients

    Seq Age Sex Outcome Treatment
    1 Other