BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    GREENLIGHT ADDSTAT

    MDR report key: 1931979 · Received November 30, 2010

    Report

    Report Number
    2937094-2010-01165
    Event Type
    Malfunction
    Date Received
    November 30, 2010
    Date of Event
    October 29, 2010
    Report Date
    November 2, 2010
    Manufacturer
    AMS INNOVATIVE CENTER- SILICONE VALLEY
    Product Code
    GEX
    PMA / PMN Number
    K062719
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    KS, US
    Reporter Occupation
    PHYSICIAN

    Narratives

    Description of Event or Problem · 1

    IT WAS REPORTED BY THE CUSTOMER THAT ON (B)(6) 2010, THE FIBER CAP DETACHED INSIDE OF THE PT AT 37,907 JOULES. ALSO, IT WAS REPORTED THAT THE FIBER CAP WAS RETRIEVED. NO PT INJURY WAS REPORTED. THE DEVICE WAS NOT RETURNED FOR EVALUATION.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 GREENLIGHT ADDSTAT SURGICAL FIBER GEX AMS INNOVATIVE CENTER- SILICONE VALLEY NA 015T

    Patients

    Seq Age Sex Outcome Treatment
    1 Other