BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    VERISOURCE

    MDR report key: 1361150 · Received January 29, 2009

    Report

    Report Number
    8020711-2009-00003
    Event Type
    Malfunction
    Date Received
    January 29, 2009
    Date of Event
    December 29, 2008
    Report Date
    January 29, 2009
    Manufacturer
    VARIAN MEDICAL SYSTEMS
    Product Code
    KXK
    PMA / PMN Number
    K061582
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CA, US
    Reporter Occupation
    OTHER

    Narratives

    Additional Manufacturer Narrative · 1

    THIS REPORT IS BASED ON INFO REC'D FROM A THIRD PARTY OR DEVELOPED BY VARIAN MEDICAL SYSTEMS. WHILE THE REPORTED EVENT IS BEING INVESTIGATED, SOME OF THE FACTS ARE AS YET UNVERIFIED. BY SUBMITTING THIS REPORT, THE COMPANY IS NOT ADMITTING THAT THE PRODUCT IDENTIFIED HAS MALFUNCTIONS, IS DEFECTIVE, OR HAS CAUSED OR CONTRIBUTED TO A SERIOUS INJURY OR DEATH. INFO PROVIDED IN THIS REPORT IS BASED ON THE ASSUMPTION THAT THE INFO CURRENTLY AVAILABLE IS TRUE AND ACCURATE.

    Description of Event or Problem · 1

    ERROR DESCRIPTION: WHILE PERFORMING THE FINAL POSITION VERIFICATION AFTER A ROUTINE SOURCE EXCHANGE ON THE VARISOURCE 200 AFTERLOADING DEVICE THE SOURCE WAS RETRACTED TO ITS PARKING POSITION INSIDE THE AFTERLOADER SHIELDING. A MANUAL RECOVERY WAS NECESSARY. WITHIN THIS EVENT NO PATIENT WAS INVOLVED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 VERISOURCE BRACHYTHERAPY SYST. REMOTE AFTERLOADING KXK VARIAN MEDICAL SYSTEMS 200 NA

    Patients

    Seq Age Sex Outcome Treatment
    1