BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    CE INFUSOR, LV 5 ML/H,12 PACK

    MDR report key: 1973262 · Received January 28, 2011

    Report

    Report Number
    6000001-2011-00506
    Event Type
    Malfunction
    Date Received
    January 28, 2011
    Date of Event
    December 30, 2010
    Report Date
    January 4, 2011
    Product Code
    MEB
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CH
    Reporter Occupation
    OTHER

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4). DEVICE EVALUATION: ONE USED SAMPLE WAS RECEIVED BY BAXTER FOR EVALUATION CONTAINING NO FLUID IN THE BLADDER. TO VERIFY THE REPORTED CONDITION, THE SAMPLE WAS FILLED WITH WATER. DURING FILLING, A BACK-FLOW WAS OBSERVED AT THE FILL-PORT DUE TO A TINY GLASS FRAGMENT FOUND UNDERNEATH THE CHECK-BAND. NO OTHER CAUSE OF BACK-FLOW WAS FOUND DURING THE EXAMINATION. THE GLASS FRAGMENT WAS INTRODUCED DURING THE FILLING PROCESS BY THE CUSTOMER. THIS IS A SINGLE USE DEVICE; THE DEVICE WILL NOT BE REPAIRED. A BATCH REVIEW WAS CONDUCTED AND NO ISSUES WERE FOUND RELATED TO THE REPORTED CONDITION DURING THE MANUFACTURE OF THE LOT.

    Additional Manufacturer Narrative · 1

    (B)(4). ADDITIONAL NARRATIVE: THE DEVICE HAS BEEN RECEIVED BY BAXTER FOR EVALUATION; HOWEVER, THE EVALUATION HAS NOT YET BEEN COMPLETED. A FOLLOW-UP REPORT WILL BE SUBMITTED UPON COMPLETION OF THE EVALUATION AND/OR SHOULD ANY ADDITIONAL INFORMATION BECOME AVAILABLE. THIS DEVICE IS MANUFACTURED FOR DISTRIBUTION OUTSIDE OF THE UNITED STATES (US); THEREFORE, IT DOES NOT CONTAIN A US 510K NUMBER. HOWEVER, THIS MDR IS BEING SUBMITTED BECAUSE IT IS THE SAME AS OR SIMILAR TO A PRODUCT DISTRIBUTED WITHIN THE US.

    Description of Event or Problem · 1

    IT WAS REPORTED TO BAXTER (B)(4) THAT ONE (1) CE INFUSOR DEVICE WAS OBSERVED LEAKING AT THE FILL PORT DURING FILLING. THERE WAS NO PATIENT INVOLVEMENT. NO ADDITIONAL INFORMATION IS AVAILABLE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 CE INFUSOR, LV 5 ML/H,12 PACK PUMP, INFUSION, ELASTOMERIC MEB 10F044

    Patients

    Seq Age Sex Outcome Treatment
    1