BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    RESTORE ULTRA

    MDR report key: 2190999 · Received July 19, 2011

    Report

    Report Number
    3004209178-2011-05575
    Event Type
    Malfunction
    Date Received
    July 19, 2011
    Date of Event
    June 1, 2011
    Report Date
    June 23, 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

    IT WAS REPORTED THAT IMPEDANCE READINGS WERE >40000 OHMS. IT WAS DETERMINED THAT 2, 3 AND 7 WERE OPEN CIRCUIT ELECTRODES. THE STIMULATOR WAS PROGRAMMED USING ELECTRODES EXCLUDING OPEN CIRCUIT ELECTRODES. THE PT REPORTED GOOD COVERAGE.

    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 IMPLANTED:| ACCESSORY: MODEL 37752, LOT# NKA119434N| IMPLANTED:| EXPLANTED:| PROGRAMMER: MODEL 37743, LOT# NKE148749N| EXTENSION: MODEL 37081, LOT# NJB046732V| IMPLANTED:| EXPLANTED:| EXPLANTED:| EXTENSION: MODEL 37081, LOT# NJB046733V| LEAD: MODEL 39565, LOT# N166024004| IMPLANTED:| EXPLANTED: