FDA Adverse Event
Malfunction
Summary report: N
EXTENSION SET
MDR report key: 2629940
·
Received June 21, 2012
Report
- Report Number
- 9616066-2012-00443
- Event Type
- Malfunction
- Date Received
- June 21, 2012
- Date of Event
- February 3, 2012
- Report Date
- June 7, 2012
- Manufacturer
- CHURCHILL MEDICAL SYSTEMS, INC.
- Product Code
- FPA
- PMA / PMN Number
- UNK
- Removal / Correction Number
- NA
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- NC, US
- Reporter Occupation
- OTHER HEALTH CARE PROFESSIONAL
Narratives
Additional Manufacturer Narrative · 1
(B)(4). (B)(6). THE DEVICE HAS BEEN RECEIVED AND THE EVAL IS PENDING. A FOLLOW UP REPORT WILL BE SUBMITTED ONCE THE EVAL HAS BEEN COMPLETED.
Description of Event or Problem · 1
CUSTOMER REPORTED THIS SET ALLOWING FLOW THAT IS FASTER THAN WHAT THEY SET IT FOR, AND "LEAKING AT CENTER OPENING." STATED THAT WHEN CONNECTED TO THE DRUG AND TURNED OFF, THE SET CONTINUES TO DRIP. THERE WAS NO PT HARM AND NO MEDICAL INTERVENTION WAS REQUIRED. ALTHOUGH REQUESTED, NO ADD'L EVENT OR PT INFO PROVIDED BY THE USER.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 1 | EXTENSION SET | FPA | CHURCHILL MEDICAL SYSTEMS, INC. | 43000E | 1108087 |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | UNK |