BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    COAGUCHEK XS SYSTEM

    MDR report key: 1761138 · Received July 13, 2007

    Report

    Report Number
    1823260-2007-06079
    Event Type
    Malfunction
    Date Received
    July 13, 2007
    Date of Event
    July 3, 2007
    Report Date
    July 13, 2007
    Manufacturer
    ROCHE DIAGNOSTICS
    Product Code
    GJS
    PMA / PMN Number
    K062925
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    SD, US
    Reporter Occupation
    OTHER

    Narratives

    Description of Event or Problem · 1

    CALLER STATES THE PATIENT TESTED 3.2 INR AND 2.4 INR ON THE COAGUCHEK SYSTEM DURING DUPLICATE TESTING. NO ACTION TAKEN ON DEVICE RESULTS. NO ADVERSE EVENT REPORTED. REQUESTED RETURN OF SUSPECT SYSTEM AND REPLACEMENT WAS SENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 COAGUCHEK XS SYSTEM PROTHROMBIN TIME TEST STRIP - GJS GJS ROCHE DIAGNOSTICS 20152531

    Patients

    Seq Age Sex Outcome Treatment
    1 NA COUMADIN - 2.5MG/DAY| AVELDART - .5MG/DAY| KLOR-CON - 10MEQ| REGLIN - 10MG/DAY| PRILOSEC - 20| ULTRAM| ALDACTONE - 25MG/DAY| BUMEX - 1MG/DAY| FLOMAX - 0.4MG/DAY