BEUDAMED
    FDA Adverse Event Injury Summary report: N

    ENDOTAK RELIANCE

    MDR report key: 3213720 · Received July 9, 2013

    Report

    Report Number
    2124215-2013-07236
    Event Type
    Injury
    Date Received
    July 9, 2013
    Date of Event
    March 1, 2013
    Report Date
    April 9, 2013
    Manufacturer
    CPI - DEL CARIBE
    Product Code
    NVY
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    NY
    Reporter Occupation
    PATIENT

    Narratives

    Additional Manufacturer Narrative · 1

    AS NO FURTHER INFORMATION CONCERNING THIS REPORT IS EXPECTED, OUR INVESTIGATION IS COMPLETE. THIS INVESTIGATION WILL BE UPDATED SHOULD FURTHER INFORMATION BE PROVIDED.

    Description of Event or Problem · 1

    BOSTON SCIENTIFIC RECEIVED INFORMATION THAT THIS LEAD WAS REVISED A MONTH AFTER IT WAS IMPLANTED DUE TO IMPROPER PLACEMENT. ADDITIONAL INFORMATION WAS RECEIVED THAT LEAD REPOSITIONING WAS PERFORMED DUE TO MICRODISLODGEMENT AS REPORTED BY THE PHYSICIAN. THE LEAD REMAINS IN SERVICE. NO ADVERSE PATIENT EFFECTS WERE REPORTED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    313679 ENDOTAK RELIANCE NVY CPI - DEL CARIBE 0296

    Patients

    Seq Age Sex Outcome Treatment
    1 54 YR Hospitalization| L| R 1688TC| 0296| E162