BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    INTERSTIM II

    MDR report key: 1854198 · Received September 30, 2010

    Report

    Report Number
    3004209178-2010-07498
    Event Type
    Malfunction
    Date Received
    September 30, 2010
    Date of Event
    January 1, 2010
    Report Date
    September 3, 2010
    Manufacturer
    MDT PUERTO RICO OPERATIONS CO., JUNCOS
    Product Code
    EZW
    PMA / PMN Number
    P970004
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    OR, US
    Reporter Occupation
    NOT APPLICABLE

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4).

    Description of Event or Problem · 1

    IT WAS REPORTED THAT THE PATIENT'S STIMULATION WAS TURNING OFF. NO ACCIDENT OR INCIDENT WAS REPORTED ASSOCIATED WITH THIS EVENT. THE PATIENT WAS AT WORK IN GOOD CONDITION. ADDITIONAL INFORMATION WAS REQUESTED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 INTERSTIM II EZW MDT PUERTO RICO OPERATIONS CO., JUNCOS 3058 NA

    Patients

    Seq Age Sex Outcome Treatment
    1 36 YR IMPLANTED:| PROGRAMMER: MODEL 3037, LOT# NJD079052N| EXPLANTED:| LEAD: MODEL LEAD, LOT# *UK6169180