BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    COAGUCHEK® XS SYSTEM

    MDR report key: 1970392 · Received January 25, 2011

    Report

    Report Number
    1823260-2011-00385
    Event Type
    Malfunction
    Date Received
    January 25, 2011
    Date of Event
    January 14, 2011
    Report Date
    March 25, 2011
    Manufacturer
    ROCHE DIAGNOSTICS
    Product Code
    GJS
    PMA / PMN Number
    K062925
    Removal / Correction Number
    NA
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    NJ, US
    Reporter Occupation
    PATIENT

    Narratives

    Description of Event or Problem · 1

    CALLER STATES HE TESTED 1.2 INR AND 4.6 INR ON THE COAGUCHEK XS SYSTEM. NO ACTIONS WERE REPORTED TAKEN OR TREATMENT RECEIVED. NO ADVERSE EVENT REPORTED. A REQUEST WAS MADE FOR THE RETURN OF THE AFFECTED PRODUCT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 COAGUCHEK® XS SYSTEM PROTHROMBIN TIME TEST STRIPS GJS ROCHE DIAGNOSTICS NA 20181121

    Patients

    Seq Age Sex Outcome Treatment
    1 076 YR LIPITOR (TWICE DAILY)| COUMADIN (TWICE DAILY)| LISINOPRIL (DAILY)| DIOVAN (DAILY)