BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    J-VAC BULB RESERVOIR

    MDR report key: 2933445 · Received January 29, 2013

    Report

    Report Number
    2210968-2013-00646
    Event Type
    Malfunction
    Date Received
    January 29, 2013
    Date of Event
    January 7, 2013
    Report Date
    January 8, 2013
    Manufacturer
    ETHICON, INC.
    Product Code
    KOG
    PMA / PMN Number
    K953655
    Removal / Correction Number
    NA
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    JA
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4). CONCLUSION: THE PRODUCT UPON WHICH THIS MEDWATCH IS BASED IS ANTICIPATED. ONCE THE PRODUCT IS RECEIVED, ANY FURTHER INFORMATION DERIVED FROM THE EVALUATION WILL BE SUBMITTED IN A SUPPLEMENTAL 3500A FORM. IN ADDITION, A REVIEW OF THE BATCH MANUFACTURING RECORDS WAS CONDUCTED AND THE BATCH MET ALL FINISHED GOODS RELEASE CRITERIA.

    Additional Manufacturer Narrative · 1

    (B)(4): THE ACTUAL DEVICE INVOLVED IN THIS EVENT WAS RETURNED FOR EVALUATION. THE VALVE WAS DETACHED AND WAS INSIDE THE RESERVOIR.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT A PATIENT UNDERWENT A PROSTATECTOMY ON (B)(6) 2013. WHEN THE NURSE CONNECTED THE DRAIN AND THE RESERVOIR, THE ANTI-REFLUX VALVE WAS DETACHED AND FELL INTO THE RESERVOIR. THE RESERVOIR WAS EXCHANGED FOR A NEW ONE WHICH WORKED NORMALLY. THERE WERE NO ADVERSE PATIENT CONSEQUENCES.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    38773 J-VAC BULB RESERVOIR WOUND DRAINAGE SYSTEM KOG ETHICON, INC. NA J1233842

    Patients

    Seq Age Sex Outcome Treatment
    1