BEUDAMED
    FDA Adverse Event Injury Summary report: N

    PATCH

    MDR report key: 1860468 · Received October 7, 2010

    Report

    Report Number
    2124215-2010-15041
    Event Type
    Injury
    Date Received
    October 7, 2010
    Date of Event
    July 22, 2010
    Report Date
    July 22, 2010
    Manufacturer
    HISTORICAL CPI ST. PAUL
    Product Code
    LWS
    PMA / PMN Number
    P830060
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    WI
    Reporter Occupation
    MEDICAL EQUIPMENT COMPANY TECHNICIAN/REPRESENTATIVE

    Narratives

    Additional Manufacturer Narrative · 1

    DUE TO THE NATURE OF THE ISSUE, NO ANALYSIS WILL BE CONDUCTED IF THE PRODUCT IS RETURNED. THIS REPORT WILL BE UPDATED IF ADDITIONAL INFORMATION IS RECEIVED.

    Description of Event or Problem · 1

    BOSTON SCIENTIFIC CRM RECEIVED INFORMATION THAT THIS PRODUCT WAS PART OF A SYSTEM EXPLANT DUE TO A PATIENT INFECTION. THERE WAS NO REPORT OF ADVERSE PATIENT EFFECTS DUE TO THE EXPLANT PROCEDURE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 PATCH IMPLANTABLE LEAD LWS HISTORICAL CPI ST. PAUL 0041

    Patients

    Seq Age Sex Outcome Treatment
    1 69 YR Required Intervention 1857| 0041| 1746| 0040| 4312| 1550| 1520| 0030| MISMATCH