BEUDAMED
    FDA Adverse Event Injury Summary report: N

    EXTENSION SET

    MDR report key: 2855131 · Received December 3, 2012

    Report

    Report Number
    1416980-2012-06387
    Event Type
    Injury
    Date Received
    December 3, 2012
    Date of Event
    October 1, 2012
    Report Date
    November 14, 2012
    Manufacturer
    BAXTER HEALTHCARE - MOUNTAIN HOME
    Product Code
    KDJ
    PMA / PMN Number
    K925403
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    US
    Reporter Occupation
    PATIENT

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4). A BATCH REVIEW WAS CONDUCTED FOR POTENTIALLY ASSOCIATED LOT NUMBERS: H12I05113, AND H12G23086. NO EXCEPTIONS WERE OBSERVED THAT WERE RELATED TO THE REPORTED CONDITION. THE PROBLEM WAS NOT CONFIRMED AND THE CAUSE OF THE PERITONITIS WAS UNDETERMINED. NO DEVICE MALFUNCTION OR USE ERROR WAS IDENTIFIED.

    Additional Manufacturer Narrative · 1

    (B)(4). THIS REPORT OF PERITONITIS WAS RECEIVED WITH NO ALLEGED DEVICE MALFUNCTION OR USE ERROR; THEREFORE, A SAMPLE WAS NOT REQUESTED. SHOULD ADDITIONAL INFORMATION BECOME AVAILABLE, A FOLLOW-UP REPORT WILL BE SUBMITTED. THIS IS REPORT 4 OF 5 INVOLVED IN THIS EVENT.

    Description of Event or Problem · 1

    THE FOLLOWING INFORMATION WAS RECEIVED FROM GLOBAL PHARMACOVIGILANCE (GPV) AND IS A SPONTANEOUS REPORT FROM A CONSUMER WITH SUPPLEMENTAL INFORMATION PROVIDED BY A NURSE IN THE USA OF FELL, HIT HER HEAD, UNCONSCIOUS, HAD A SEIZURE, HYPERTENSION AND PERITONITIS IN A PATIENT COINCIDENT WITH DIANEAL PD4 AMBUFLEX AND EXTRANEAL VIAFLEX THERAPIES. DURING A CALL WITH BAXTER CUSTOMER SERVICES, THE FOLLOWING WAS REPORTED. IT WAS REPORTED BY THE PERITONEAL DIALYSIS NURSE THAT SHE BELIEVED THE PATIENT HAD ACQUIRED PERITONITIS DURING A PREVIOUS HOSPITALIZATION ON (B)(6) 2012 FOR AN EVENT OF FALLING, HITTING HEAD, FOUND UNCONSCIOUS, AND HAD A SEIZURE DUE TO HAVING HYPERTENSION. THE PATIENT WAS DISCHARGED HOME FROM THE HOSPITAL ON (B)(6) 2012. ON (B)(6) 2012, THE PATIENT WAS HOSPITALIZED FOR PERITONITIS. TREATMENT RENDERED FOR THE PERITONITIS WAS NOT REPORTED. ON (B)(6) 2012, THE PATIENT WAS DISCHARGED FROM THE HOSPITAL. THE CAUSE OF THE PERITONITIS WAS UNKNOWN. THE PATIENT RECOVERED FROM THE SEIZURE AND HYPERTENSION ON (B)(6) 2012. THE PATIENT WAS RECOVERING FROM HITTING HER HEAD AND PERITONITIS. SEIZURE, HYPERTENSION AND PERITONITIS WERE UNRELATED TO BAXTER PRODUCTS.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 EXTENSION SET SET, ADMINISTRATION, FOR PERITONEAL DIALYSIS, DISPOSABLE KDJ BAXTER HEALTHCARE - MOUNTAIN HOME

    Patients

    Seq Age Sex Outcome Treatment
    1 40 YR Hospitalization DIANEAL PD4 AMBUFLEX| EXTRANEAL VIAFLEX