BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    COAGUCHEK® XS SYSTEM

    MDR report key: 1953083 · Received January 7, 2011

    Report

    Report Number
    1823260-2011-00128
    Event Type
    Malfunction
    Date Received
    January 7, 2011
    Date of Event
    December 1, 2010
    Report Date
    February 28, 2011
    Manufacturer
    ROCHE DIAGNOSTICS
    Product Code
    GJS
    PMA / PMN Number
    NA
    Removal / Correction Number
    NA
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Occupation
    MEDICAL EQUIPMENT COMPANY TECHNICIAN/REPRESENTATIVE

    Narratives

    Additional Manufacturer Narrative · 1

    THE EVENT OCCURRED IN (B)(6).

    Description of Event or Problem · 1

    CALLER STATES PATIENT TESTED 4.4 INR AND 4.1 INR ON THE COAGUCHEK XS PLUS SYSTEM WHILE COMPARISON LABS RETURNED AS 2.98 AND 2.98 INR. NO TREATMENT INFORMATION PROVIDED. NO ADVERSE EVENT REPORTED. REQUESTED RETURN OF SUSPECT SYSTEM AND REPLACEMENT WAS SENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 COAGUCHEK® XS SYSTEM PROTHROMBIN TIME TEST STRIPS GJS ROCHE DIAGNOSTICS NA 20130913

    Patients

    Seq Age Sex Outcome Treatment
    1 066 YR RAMIPRIL| CYMBALTA| SIMVASTATIN| "FURIX"| "CELOZOX"| ELTROXIN| ARTIFICIAL HEART VALVE| MAREVAN| "CALCEORID"| CALCIUM "SANDAX"