BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    OCTRODE

    MDR report key: 3040276 · Received April 3, 2013

    Report

    Report Number
    1627487-2013-05478
    Event Type
    Malfunction
    Date Received
    April 3, 2013
    Date of Event
    March 5, 2013
    Report Date
    March 5, 2013
    Manufacturer
    ST. JUDE MEDICAL - NEUROMODULATION
    Product Code
    LGW
    PMA / PMN Number
    P010032
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    TX, US
    Reporter Occupation
    NOT APPLICABLE

    Narratives

    Additional Manufacturer Narrative · 1

    SJM HAS LIMITED INFO RELATED TO THE PT'S MEDICAL HISTORY AND IS UNABLE TO FORM AN OPINION AS TO THE RELEVANCY OF THE PT'S HISTORY TO THE EVENT REPORTED. SJM DEFERS TO THE PT'S PHYSICIAN REGARDING MEDICAL HISTORY.

    Description of Event or Problem · 1

    DEVICE 4 OF 4. REFERENCE MFR REPORT #: 1627487-2013-05200. REFERENCE MFR REPORT #: 1627487-2013-05201. REFERENCE MFR REPORT #: 1627487-2013-05477.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    135886 OCTRODE SCS LEAD LGW ST. JUDE MEDICAL - NEUROMODULATION 3186 3399964

    Patients

    Seq Age Sex Outcome Treatment
    1 53 YR Required Intervention IMPLANTED:| SCS ANCHORS: MODEL 1192 (X2)