BEUDAMED
    FDA Adverse Event Injury Summary report: N

    INTERSTIM II

    MDR report key: 2031565 · Received March 25, 2011

    Report

    Report Number
    3004209178-2011-02125
    Event Type
    Injury
    Date Received
    March 25, 2011
    Date of Event
    March 1, 2011
    Report Date
    March 11, 2011
    Manufacturer
    MDT PUERTO RICO OPERATIONS CO., JUNCOS
    Product Code
    EZW
    PMA / PMN Number
    P970004
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    MA, US
    Reporter Occupation
    NOT APPLICABLE

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4).

    Description of Event or Problem · 1

    IT WAS REPORTED THAT THE PT'S WIRE CAME THROUGH HER SKIN NEAR HER BUTTOCKS. THE PT WAS IN PAIN. THERE WAS NO INCIDENT OR ACCIDENT RELATED TO THIS EVENT. ADDITIONAL INFO FROM THE PTS PHYSICIAN WAS REQUESTED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 INTERSTIM II EZW MDT PUERTO RICO OPERATIONS CO., JUNCOS 3058 NA

    Patients

    Seq Age Sex Outcome Treatment
    1 56 YR Other IMPLANTED:| PROGRAMMER: MODEL 3037, LOT# NJD098761N| LEAD: MODEL 3093, LOT# V432838| EXPLANTED: