BEUDAMED
    FDA Adverse Event Injury Summary report: N

    UNKNOWN

    MDR report key: 2100912 · Received May 19, 2011

    Report

    Report Number
    MW5020653
    Event Type
    Injury
    Date Received
    May 19, 2011
    Date of Event
    April 4, 2011
    Report Date
    May 12, 2011
    Manufacturer
    UNKNOWN
    Product Code
    KNT
    Adverse Event
    Yes
    Report Source
    Voluntary report
    Reporter Location
    NY, US
    Reporter Occupation
    RISK MANAGER

    Narratives

    Description of Event or Problem · 1

    A (B)(6) FEMALE ADMITTED FROM (B)(6) TO THE ED FOR PEG REPLACEMENT. PEG REPLACED ON (B)(6) 2010 AT (B)(6). DURING THE REMOVAL OF THE PEG TUBE, THE TUBE DISC GOT DISLODGED AS THE SNARE SNAPPED WITH DISAPPEARANCE OF THE DISC AT THE CRICOPHARYNGEAL AREA. PROCEDURE: ESOPHAGOGASTRODUODENOSCOPY REMOVAL OF DETERIORATED PEG TUBE, AND INSERTION OF NEW PEG TUBE. ON (B)(6) 2009 - PEG 20F INSERTED. ON (B)(6) 2010 - PEG REPLACED (B)(6). ON (B)(6) 2011 - PEG REPLACED 20F.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 UNKNOWN PEG 20F KNT UNKNOWN

    Patients

    Seq Age Sex Outcome Treatment
    1 92 YR Hospitalization