BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    HOMECHOICE

    MDR report key: 2974473 · Received February 22, 2013

    Report

    Report Number
    1416980-2013-04483
    Event Type
    Malfunction
    Date Received
    February 22, 2013
    Date of Event
    December 2, 2012
    Report Date
    February 4, 2013
    Manufacturer
    BAXTER HEALTHCARE - LARGO
    Product Code
    FKX
    PMA / PMN Number
    K102936
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    TH
    Reporter Occupation
    PATIENT

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4). THE DEVICE WAS RETURNED TO BAXTER, AND THE EVALUATION IS COMPLETE. THIS COMPLAINT IS AN ANCILLARY SERVICE EVENT. THE REPORTED DIFFICULTY OF AN IIPV EVENT WAS CONFIRMED THROUGH AN EVENT HISTORY LOG REVIEW. THE CAUSE WAS UNDETERMINED. IF ADDITIONAL RELEVANT INFORMATION IS RECEIVED, A FOLLOW-UP WILL BE SENT.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT DURING SERVICING OF A HOMECHOICE DEVICE, A HIGH DRAIN ERROR 101 HIGH DRAIN ERROR 101 ALARM WAS IDENTIFIED AS HAVING OCCURRED ON (B)(6) 2012, 06:29:46, DURING NIGHT DRAIN 1. THE ALARM INDICATES AN IIPV EVENT HAD OCCURRED DURING THERAPY. NO ADDITIONAL INFORMATION IS AVAILABLE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    78277 HOMECHOICE SYSTEM, PERITONEAL, AUTOMATIC DELIVERY FKX BAXTER HEALTHCARE - LARGO

    Patients

    Seq Age Sex Outcome Treatment
    1