BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    RESTORE ULTRA

    MDR report key: 2101713 · Received May 11, 2011

    Report

    Report Number
    3004209178-2011-03404
    Event Type
    Malfunction
    Date Received
    May 11, 2011
    Date of Event
    April 19, 2011
    Report Date
    April 19, 2011
    Manufacturer
    MDT PUERTO RICO OPERATIONS CO., JUNCOS
    Product Code
    LGW
    PMA / PMN Number
    P840001
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    GA, US
    Reporter Occupation
    NOT APPLICABLE

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4).

    Description of Event or Problem · 1

    IT WAS REPORTED, THERE WAS A POWER ON RESET (POR) CONDITION, AND THE PT COULD NOT ADJUST STIMULATION. THE POR WAS CLEARED AND THE ISSUE WAS 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 55 YR EXTENSION: MODEL 37081, LOT# NJB043972V| EXPLANTED:| EXPLANTED:| IMPLANTED:| PROGRAMMER: MODEL 37743, LOT# NKE116921N| EXTENSION: MODEL 37081, LOT# NJB043969V| ACCESSORY: MODEL 37752, LOT# NKA119705N| IMPLANTED:| LEAD: MODEL 39565-30, LOT# N168029003| EXPLANTED:| IMPLANTED: