BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    12 FT. EXTENSION SET, EASY LOCK CONNECTOR

    MDR report key: 254814 · Received December 13, 1999

    Report

    Report Number
    1423500-1999-01497
    Event Type
    Malfunction
    Date Received
    December 13, 1999
    Date of Event
    November 26, 1999
    Report Date
    November 26, 1999
    Manufacturer
    BAXTER HEALTHCARE CORP.
    Product Code
    KDJ
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    NJ, US
    Reporter Occupation
    UNKNOWN

    Narratives

    Description of Event or Problem · 1

    HOME PT (HP) REPORTS "EXTREME" SHOULDER PAIN DUE TO EXCESS AIR. HP REPORTS SHE WAS NOT PRIMING HER PT 12 FT. EXTENSION SET PROPERLY. HP REPORTS THE PAIN HAS DISSIPATED AND NO MEDICAL INTERVENTION HAS BEEN NECESSARY. HP NOTES SHE NOTIFIED DR. AND NO X-RAY WAS TAKEN.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 12 FT. EXTENSION SET, EASY LOCK CONNECTOR EXTENSION LINE KDJ BAXTER HEALTHCARE CORP. NA NA01

    Patients

    Seq Age Sex Outcome Treatment
    1 UNKNOWN HOMECHOICE AUTOMATED PD SET W/CASSETTE 4-PRONG.