BEUDAMED
    FDA Adverse Event Death Summary report: N

    PICC LINE

    MDR report key: 1132730 · Received August 21, 2008

    Report

    Report Number
    MW5008051
    Event Type
    Death
    Date Received
    August 21, 2008
    Date of Event
    August 19, 2008
    Report Date
    August 21, 2008
    Manufacturer
    UNK
    Product Code
    LJS
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Voluntary report
    Reporter Location
    NY, US
    Reporter Occupation
    PHYSICIAN

    Narratives

    Description of Event or Problem · 1

    CARDIAC TAMPONADE DUE TO HEMOPERICARDIUM FOLLOWING REMOVAL OF BROKEN PICC -10CM FRAGMENT RECOVERED FROM PULMONARY ARTERY- AND REINSERTION OF CENTRAL LINE FOR CHEMOTHERAPY TREATMENT OF COLON CANCER. FROM HISTORY AND AUTOPSY RESULTS. DIAGNOSIS OR REASON FOR USE: CHEMOTHERAPY PORT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 PICC LINE PICC - USED AT ONCOLOGY- LJS UNK

    Patients

    Seq Age Sex Outcome Treatment
    1 73 YR Death| S