BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    RESTORE ULTRA

    MDR report key: 2031392 · Received March 16, 2011

    Report

    Report Number
    3004209178-2011-02008
    Event Type
    Malfunction
    Date Received
    March 16, 2011
    Date of Event
    March 1, 2011
    Report Date
    March 1, 2011
    Manufacturer
    MDT PUERTO RICO OPERATIONS CO., JUNCOS
    Product Code
    LGW
    PMA / PMN Number
    P840001
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    MN, US
    Reporter Occupation
    NOT APPLICABLE

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4).

    Description of Event or Problem · 1

    RECEIVED INFO THE PT EXPERIENCED A POWER ON RESET CONDITION ON HIS PT PROGRAMMER. PT HAD NOT HAD AN X-RAYS OR PROCEDURES. HE WAS AT THE AIRPORT ABOUT A MONTH AGO. THE POR WAS CLEARED BY THE MFR'S REP AND PROBLEM RESOLVED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 RESTORE ULTRA LGW MDT PUERTO RICO OPERATIONS CO., JUNCOS 37712 NA

    Patients

    Seq Age Sex Outcome Treatment
    1 61 YR PROGRAMMER: MODEL 37743, LOT# NKE132040N| EXPLANTED:| IMPLANTED:| LEAD: MODEL 39565-65, LOT# N210287003