BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    LIFEVEST WCD 3100 SYSTEM

    MDR report key: 1811202 · Received August 11, 2010

    Report

    Report Number
    3002158293-2010-00824
    Event Type
    Malfunction
    Date Received
    August 11, 2010
    Date of Event
    June 23, 2010
    Report Date
    August 10, 2010
    Manufacturer
    ZOLL LIFECOR CORPORATION
    Product Code
    MVK
    PMA / PMN Number
    P010030
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Occupation
    UNKNOWN

    Narratives

    Additional Manufacturer Narrative · 1

    DEVICE EVALUATION SUMMARY: DEVICE EVALUATION OF ELECTRODE BELT (B)(4) HAS BEEN COMPLETED. THE REPORTED PROBLEM HAS BEEN CONFIRMED. UPON INSPECTION, THE ELECTRODE BELT WAS FOUND TO HAVE THE CONNECTOR PINS BENT. THE ELECTRODE BELT CONNECTOR PINS DID NOT SUCCESSFULLY MATE WITH THE CONNECTOR, RESULTING IN A GELLED BELT. THE ROOT CAUSE OF THE BENT PINS CANNOT BE POSITIVELY IDENTIFIED BUT WAS LIKELY DUE TO THE CONNECTOR BEING FORCED INTO THE MONITOR WHILE THE PINS WERE MISALIGNED. NO ADVERSE EVENT RESULTED FROM THE BENT CONNECTOR PINS. THE PT RECEIVED A REPLACEMENT ELECTRODE BELT.

    Description of Event or Problem · 1

    THE PT SERVICE REPRESENTATIVE (PSR) ASSISTING A (B)() OLD MALE PT CONTACTED ZOLL LIFECOR CUSTOMER SUPPORT TO REPORT THAT THERE WAS BLUE GEL PRESENT ON THE FRONT THERAPY ELECTRODE PAD. THE PT RECEIVED A REPLACEMENT ELECTRODE BELT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 LIFEVEST WCD 3100 SYSTEM WEARABLE CARDIOVERTER DEFIBRILLATOR MVK ZOLL LIFECOR CORPORATION WCD 3100 NA

    Patients

    Seq Age Sex Outcome Treatment
    1 55 YR