BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    V. MUELLER

    MDR report key: 1932673 · Received December 15, 2010

    Report

    Report Number
    MW5018606
    Event Type
    Malfunction
    Date Received
    December 15, 2010
    Date of Event
    December 7, 2010
    Report Date
    December 14, 2010
    Manufacturer
    CAREFUSION
    Product Code
    KBN
    Product Problem
    Yes
    Report Source
    Voluntary report
    Reporter Location
    CO, US
    Reporter Occupation
    OTHER

    Narratives

    Description of Event or Problem · 1

    DR PLACED MCIVOR MOUTH GAG IN PT'S MOUTH. THE MAYO STAND WAS BROUGHT IN OVER PT'S CHEST AND MOUTH GAG ATTACHED. MAYO STAND WAS ELEVATED TO PROVIDE TRACTION AND EXPOSE TONSILS. THE MCIVOR MOUTH GAG BROKE AT WELD UPON ELEVATION AND EXPOSURE WAS LOST. NO INJURY TO PT. (B)(4).

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 V. MUELLER MCIVOR MOUTH GAG KBN CAREFUSION MO 156

    Patients

    Seq Age Sex Outcome Treatment
    1 55 YR