BEUDAMED
    FDA Adverse Event Injury Summary report: N

    BARD ACCESS SYSTEMS

    MDR report key: 1276143 · Received December 30, 2008

    Report

    Report Number
    MW5009463
    Event Type
    Injury
    Date Received
    December 30, 2008
    Date of Event
    December 2, 2008
    Report Date
    December 30, 2008
    Manufacturer
    BARD ACCESS SYSTEMS INC.
    Product Code
    LJS
    Product Problem
    Yes
    Report Source
    Voluntary report
    Reporter Location
    MN, US
    Reporter Occupation
    NURSE

    Narratives

    Description of Event or Problem · 1

    PT CAME TO ER BECAUSE PICC BROKE. PT PUT CLAMP FROM HOME IV INFUSION SET INTO TUBING. PICC SEPARATED JUST BELOW THE HUB. PT NOTED PROBLEM AFTER SHOWER.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 BARD ACCESS SYSTEMS CENTRAL VENOUS CATHETERS-SINGLE LUMEN BARD GROSHONG NT LJS BARD ACCESS SYSTEMS INC. 9617408 RESG0671

    Patients

    Seq Age Sex Outcome Treatment
    1 49 YR Hospitalization