BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    INTERSTIM

    MDR report key: 3811428 · Received May 15, 2014

    Report

    Report Number
    3004209178-2014-08964
    Event Type
    Malfunction
    Date Received
    May 15, 2014
    Report Date
    April 23, 2014
    Manufacturer
    MEDTRONIC MED REL MEDTRONIC PUERTO RICO
    Product Code
    EZW
    PMA / PMN Number
    P970004
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    OR, US
    Reporter Occupation
    OTHER

    Narratives

    Additional Manufacturer Narrative · 1

    CONCOMITANT: PRODUCT ID 3037, SERIAL# (B)(4), IMPLANTED: 2009-(B)(6), PRODUCT TYPE PROGRAMMER, PATIENT PRODUCT ID 3889-28, LOT# V249003, IMPLANTED: 2009-(B)(6), PRODUCT TYPE LEAD. PRODUCT ID 3095-10, SERIAL# (B)(4), IMPLANTED: 2009-(B)(6), PRODUCT TYPE EXTENSION. (B)(4).

    Description of Event or Problem · 1

    IT WAS NOTED THAT THE PATIENT HAD TWO IMPLANTABLE NEUROSTIMULATORS. ONE WAS A SPINAL CORD STIMULATOR AND ONE WAS FOR URINARY STIMULATION. BOTH OF THE DEVICES WERE IMPLANTED IN THE PATIENT¿S RIGHT BUTTOCK AREA. ONE OF THE TWO IMPLANTABLE NEUROSTIMULATORS MOVED TO THE LEFT SIDE ON ITS OWN ABOUT 3 DAYS PRIOR TO THE REPORT. ADDITIONAL INFORMATION HAS BEEN REQUESTED, BUT WAS NOT AVAILABLE AS OF THE DATE OF THIS REPORT. IF ADDITIONAL INFORMATION IS RECEIVED, A FOLLOW UP REPORT WILL BE SENT. IT WAS UNCLEAR WHICH IMPLANTABLE NEUROSTIMULATOR (INS) MOVED. PLEASE REFER TO MANUFACTURER REPORT # 3004209178-2014-08963 FOR INFORMATION REGARDING THE SPINAL CORD STIMULATOR INS.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    289993 INTERSTIM STIMULATOR, ELECTRICAL, IMPLANTABLE, FOR INCONTINENCE EZW MEDTRONIC MED REL MEDTRONIC PUERTO RICO 3023

    Patients

    Seq Age Sex Outcome Treatment
    1