BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    TEMPORARY PACING WIRE

    MDR report key: 3113383 · Received May 15, 2013

    Report

    Report Number
    2210968-2013-05553
    Event Type
    Malfunction
    Date Received
    May 15, 2013
    Date of Event
    April 22, 2013
    Report Date
    April 23, 2013
    Manufacturer
    ETHICON, INC.
    Product Code
    LDF
    PMA / PMN Number
    K781002
    Removal / Correction Number
    NA
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    JA
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4) - ADDITIONAL INFORMATION WAS RECEIVED THAT INDICATES THIS EVENT DOES NOT MEET REPORTING CRITERIA. THIS EVENT IS THEREFORE NOT REPORTABLE.

    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. THIS IS ONE OF THREE MEDWATCHES BEING SUBMITTED AS THREE DEVICES WERE INVOLVED IN THIS EVENT. SEE ALSO MEDWATCH 2210968-2013-05554 AND 2210968-2013-05555. THE SAME PATIENT IS REPRESENTED IN EACH MEDWATCH.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT A PATIENT UNDERWENT AN UNKNOWN PROCEDURE ON (B)(6) 2013 AND SUTURE WAS USED. THE SUTURE BROKE WHEN THE SURGEON SET UP THE ADAPTER PLUG. THERE WAS NO ADVERSE CONSEQUENCE TO THE PATIENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    214050 TEMPORARY PACING WIRE ELECTRODE, PACEMAKER, TEMP LDF ETHICON, INC. NA EL8GHXM0

    Patients

    Seq Age Sex Outcome Treatment
    1