BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    PICC LINE

    MDR report key: 3840174 · Received May 22, 2014

    Report

    Report Number
    MW5036330
    Event Type
    Malfunction
    Date Received
    May 22, 2014
    Date of Event
    May 13, 2014
    Report Date
    May 21, 2014
    Manufacturer
    BARD
    Product Code
    LJS
    Product Problem
    Yes
    Report Source
    Voluntary report
    Reporter Location
    IL, US
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL

    Narratives

    Description of Event or Problem · 1

    INFANT FOUND WITH PCVC DRESSING INTACT, AND PCVC CATHETER BROKEN OFF FROM ANCHOR DEVICE. LINE WAS DISCONTINUED, PARENTS WERE NOTIFIED. DOCTOR AWARE. INFANT SHOWED NO SIGNS OF HARM.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    304386 PICC LINE PICC LINE LJS BARD PER-Q-CATH PICC REXL0169

    Patients

    Seq Age Sex Outcome Treatment
    1 58 YR