BEUDAMED
    FDA Adverse Event Injury Summary report: N

    QUATTRODE

    MDR report key: 3931792 · Received June 23, 2014

    Report

    Report Number
    1627487-2014-21416
    Event Type
    Injury
    Date Received
    June 23, 2014
    Date of Event
    June 2, 2014
    Report Date
    June 2, 2014
    Manufacturer
    ST. JUDE MEDICAL - NEUROMODULATION
    Product Code
    GZF
    PMA / PMN Number
    K072462
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    TX, US
    Reporter Occupation
    NOT APPLICABLE

    Narratives

    Additional Manufacturer Narrative · 1

    SJM HAS LIMITED INFORMATION RELATED TO THE PATIENT'S MEDICAL HISTORY AND IS UNABLE TO FORM AN OPINION AS TO THE RELEVANCY OF THE PATIENT'S HISTORY TO THE EVENT REPORTED. SJM DEFERS TO THE PATIENT'S PHYSICIAN REGARDING MEDICAL HISTORY.

    Description of Event or Problem · 1

    DEVICE 1 OF 2. REFERENCE MFR REPORT: 1627487-2014-21417. THE PATIENT RECEIVED FOUR LEADS, EACH PAIR HAS THE SAME LOT NUMBER. IT WAS REPORTED ONE OF THE PATIENT'S LEADS ERODED THROUGH HER SKIN. ADDITIONALLY, THE PATIENT STATED SHE NO LONGER NEEDS THE SYSTEM DUE TO IMPROVED PAIN. AS A RESULT, THE ENTIRE SCS SYSTEM WAS EXPLANTED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    367351 QUATTRODE SCS LEAD GZF ST. JUDE MEDICAL - NEUROMODULATION 3166 3199480

    Patients

    Seq Age Sex Outcome Treatment
    1 17 YR Other IMPLANT DATE:| SCS IPG: MODEL 3788| IMPLANT DATE:| SCS EXTENSIONS: MODEL 3346 (2)