BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    POWERED WHEELCHAIR

    MDR report key: 2760217 · Received September 26, 2012

    Report

    Report Number
    1525712-2012-01603
    Event Type
    Malfunction
    Date Received
    September 26, 2012
    Report Date
    September 25, 2012
    Manufacturer
    INVACARE TAYLOR STREET
    Product Code
    ITI
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    MI, US
    Reporter Occupation
    PATIENT

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4). NO RMA HAS BEEN INITIATED FOR THIS ISSUE. MODEL PRONTO M61 , SERIAL NUMBER/DATE CODE IS UNKNOWN AND THE AGE OF THE DEVICE IS UNKNOWN. THE OWNER'S MANUAL PART NUMBER 1125085 WAS ISSUED WITH THIS DEVICE. THE OWNER'S MANUAL IS ALSO FOUND ON-LINE AT INVACARE.COM. IT IS UNKNOWN IF THE CONSUMER HAS FULLY READ AND UNDERSTANDS THE OWNER'S MANUAL. DOCUMENTATION PROVIDES WARNINGS, CAUTIONS, AND INSTRUCTIONS FOR SAFELY USING THE DEVICE. IF THE CONSUMER DOES NOT UNDERSTAND THE WRITTEN WARNINGS, CAUTIONS OR INSTRUCTIONS THEN THEY SHOULD CONTACT INVACARE. THE CONSUMER'S AGE, HEIGHT AND WEIGHT ARE UNKNOWN. THE CONSUMER'S MEDICAL CONDITION, STABILITY AND MEDICATION REGIMEN ARE UNKNOWN. THE CONSUMER'S TECHNIQUE WHILE USING THE DEVICE IS UNKNOWN. THE MAINTENANCE HISTORY OF THE DEVICE IS UNKNOWN. THE MALFUNCTION HAS NOT BEEN CONFIRMED. A CALL WAS PLACED TO THE REPORTER OF THE EVENT AND TO DATE NO FURTHER INFORMATION HAS BEEN RECEIVED.

    Description of Event or Problem · 1

    CUSTOMER SAT DOWN IN THE CHAIR AND THE FRONT RIGHT WHEEL BROKE. CUSTOMER ALLEGES NO INJURY HAS OCCURRED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 POWERED WHEELCHAIR 890.3860 ITI INVACARE TAYLOR STREET PRONTO M61

    Patients

    Seq Age Sex Outcome Treatment
    1 Other