BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    MICROCLACE MED INC - HOSPIRA

    MDR report key: 1783012 · Received July 23, 2010

    Report

    Report Number
    MW5016915
    Event Type
    Malfunction
    Date Received
    July 23, 2010
    Date of Event
    July 22, 2010
    Report Date
    July 23, 2010
    Product Code
    FPA
    Product Problem
    Yes
    Report Source
    Voluntary report
    Reporter Location
    NE, US
    Reporter Occupation
    RISK MANAGER

    Narratives

    Description of Event or Problem · 1

    ON THE SURGICAL FLOOR THE NURSE WAS ROUNDING ON A PT AND SAW THAT THE PT WAS BLEEDING FROM HIS IV. THE LUER LOCK CONNECTING SITE BY THE BLUE PORT OF AN IV EXTENSION SET CLAVE WAS DISCONNECTED FROM THE TUBING. THERE WAS NO COMPLICATION TO THE PT. THE IV WAS DC'D WITHOUT INCIDENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 MICROCLACE MED INC - HOSPIRA IV EXTENSION WITH CLAVE FPA 12551

    Patients

    Seq Age Sex Outcome Treatment
    1 83 YR