BEUDAMED
    FDA Adverse Event Death Summary report: N

    FR2

    MDR report key: 1743397 · Received June 29, 2010

    Report

    Report Number
    3030677-2010-00196
    Event Type
    Death
    Date Received
    June 29, 2010
    Date of Event
    October 7, 2009
    Report Date
    June 29, 2010
    Manufacturer
    PHILIPS MEDICAL SYSTEMS, HEARTSTREAM
    Product Code
    MKJ
    PMA / PMN Number
    003565
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    MA, US
    Reporter Occupation
    NOT APPLICABLE

    Narratives

    Additional Manufacturer Narrative · 1

    METHOD: ECG AND INTERNAL DEVICE MEMORY ASSOCIATED WITH INCIDENT REVIEWED. RESULTS: ECG MORPHOLOGY CHANGED DURING INCIDENT TO A NON-SHOCKABLE RHYTHM. NO SHOCK WAS ADVISED, AND NO SHOCK WAS DELIVERED.

    Description of Event or Problem · 1

    SUBJECT WAS NOT RESUSCITATED. (B) (4).

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 FR2 AED MKJ PHILIPS MEDICAL SYSTEMS, HEARTSTREAM M3860A-ABA

    Patients

    Seq Age Sex Outcome Treatment
    1 84 YR Death