FDA Adverse Event Other Summary report: N

8030916-2008-00012

MDR report key: 1032554 · Received April 14, 2008

Report

Report Number
8030916-2008-00012
Event Type
Other
Date Received
April 14, 2008
Product Code
KME
Report Source
Manufacturer report

Narratives

Additional Manufacturer Narrative · 1

IT WAS DISCOVERED DURING THE ON-SITE INVESTIGATION THAT THE SHEET HAD BEEN INCORRECTLY USED DURING THE PT LIFT. ONLY THE TWO UPPER PAIR OF STRAPS WERE USED, INSTEAD OF THREE TO FOUR WHICH IS RECOMMENDED IN THE INSTRUCTION GUIDE. THE LIFTING STRAPS WERE TURNED TOWARDS THE PT, RATHER THAN AWAY FROM THE BODY AND THE SHEET WAS PULLED DURING THE TRANSFER PROCESS, RATHER THAN USING THE SHEET STRAPS. PICTURES OF THE SHEET SHOW NO DIVERGENCE FROM SPEC. THE PROBLEM COULD NOT BE RECREATED WHEN A NEW SHEET WAS USED ACCORDING TO THE INSTRUCTION GUIDE.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 KME

Patients

Seq Age Sex Outcome Treatment
1