FDA Adverse Event Death Summary report: N

DISPOSABLE BAG MASK RESUSCITATOR

MDR report key: 134 · Received January 28, 1992

Report

Report Number
134
Event Type
Death
Date Received
January 28, 1992
Date of Event
January 7, 1992
Report Date
January 10, 1992
Manufacturer
LIFE SUPPORT PRODUCTS, INC.
Product Code
KGB
Adverse Event
Yes
Report Source
User Facility report

Narratives

Description of Event or Problem · 1

REPORTED OCCLUSION OF RELIEF HOLE AT END OF RESERVOIR BAG AND INTERMITTENT STICKING OF RED NON-REBREATHING VALVE WHILE IN USE DURING TRANSPORT OF PATIENT FROM CUCOR TO CCU RECOVERY. PATIENT SUFFERED CARDIAC ARREST AND EXPIREDDEVICE LABELED FOR SINGLE USE. PATIENT MEDICAL STATUS PRIOR TO EVENT: FAIR CONDITION. THERE WAS NOT MULTIPLE PATIENT INVOLVEMENT.INVALID DATA - ON DEVICE SERVICE/MAINTENANCE. NO DATA - REGARDING DATE LAST SERVICED. SERVICE PROVIDED BY: INVALID DATA. INVALID DATA - SERVICE RECORDS AVAILABILITY. IMMINENT HAZARD TO PUBLIC HEALTH CLAIMED. DEVICE USED AS LABELED/INTENDED.DEVICE WAS EVALUATED AFTER THE EVENT. METHOD OF EVALUATION: ACTUAL DEVICE INVOLVED IN INCIDENT WAS EVALUATED, PERFORMANCE TESTS PERFORMED, VISUAL EXAMINATION. RESULTS OF EVALUATION: COMPONENT FAILURE, TELEMETRY FAILURE, VALVE. CONCLUSION: DEVICE FAILURE OCCURRED AND WAS RELATED TO EVENT, OTHER. CERTAINTY OF DEVICE AS CAUSE OF OR CONTRIBUTOR TO EVENT: INVALID DATA. CORRECTIVE ACTIONS: DEVICE PERMANENTLY REMOVED FROM SERVICE. THE DEVICE WAS NOT DESTROYED/DISPOSED OF.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 DISPOSABLE BAG MASK RESUSCITATOR KGB LIFE SUPPORT PRODUCTS, INC. 470-040 108548

Patients

Seq Age Sex Outcome Treatment
1 81 YR Death