BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    LIFEVEST WCD 4000 SYSTEM

    MDR report key: 3073081 · Received April 8, 2013

    Report

    Report Number
    3008642652-2013-00945
    Event Type
    Malfunction
    Date Received
    April 8, 2013
    Date of Event
    March 4, 2013
    Report Date
    April 3, 2013
    Manufacturer
    ZOLL LIFECOR CORPORATION
    Product Code
    MVK
    PMA / PMN Number
    P010030
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Occupation
    NOT APPLICABLE

    Narratives

    Additional Manufacturer Narrative · 1

    DEVICE EVALUATION SUMMARY: DEVICE EVALUATION OF ELECTRODE BELT SN (B)(4) HAS BEEN COMPLETED. THE REPORTED PROBLEM (SERVICE CODE 204, DAMAGED CONNECTOR) HAS BEEN CONFIRMED. UPON INVESTIGATION THE TRUNK CABLE CONNECTOR WAS CRACKED AND THE BLUE (CAN L), WHITE (DRVN_GND), ORANGE (+5V), BROWN (-5V), AND BLACK (MAIN BATT) WIRES WERE OPEN WITHIN THE CONNECTOR, WHICH CAUSED THE REPORTED SERVICE CODE 204. THE CAUSE FOR THE OPEN WIRES WAS THE DAMAGE TO THE TRUNK CABLE CONNECTOR. THE ROOT CAUSE FOR THE CRACKED TRUNK CABLE CONNECTOR COULD NOT BE POSITIVELY IDENTIFIED BUT WAS LIKELY EXCESSIVE FORCE. NO ADVERSE EVENT RESULTED FROM THE OPEN WIRES. THE PATIENT RECEIVED A REPLACEMENT ELECTRODE BELT.

    Description of Event or Problem · 1

    A (B)(6) MALE PATIENT CALLED ZOLL CUSTOMER SUPPORT TO REPORT THAT HE WAS RECEIVING A SERVICE CODE 204 AND THAT THE ELECTRODE BELT CONNECTOR WAS DAMAGED. THE PATIENT WAS ISSUED A REPLACEMENT ELECTRODE BELT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    142822 LIFEVEST WCD 4000 SYSTEM WEARABLE CARDIOVERTER DEFIBRILLATOR MVK ZOLL LIFECOR CORPORATION WCD 4000 NA

    Patients

    Seq Age Sex Outcome Treatment
    1 26 YR