BEUDAMED
    FDA Adverse Event Injury Summary report: N

    POWERED WHEELCHAIR

    MDR report key: 4112957 · Received September 24, 2014

    Report

    Report Number
    1525712-2014-06244
    Event Type
    Injury
    Date Received
    September 24, 2014
    Date of Event
    July 13, 2014
    Report Date
    September 5, 2014
    Manufacturer
    INVACARE TAYLOR STREET
    Product Code
    ITI
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    NM, US
    Reporter Occupation
    PATIENT

    Narratives

    Description of Event or Problem · 1

    END USER STATED THAT HE WAS GOING DOWN THE SIDEWALK IN HIS (B)(4) POWER CHAIR WHEN THE FRONT CASTERS GOT CAUGHT IN THE CRACK OF THE SIDEWALK CAUSING THE CHAIR TO FLIP OVER. END USER SUSTAINED A BROKEN LEFT BIG TOE, LEFT HIP AND KNEE WERE PARTIALLY DISLOCATED, BROKE LEFT WRIST, PARTIAL DISLOCATION OF LEFT SHOULDER, RIGHT SHOULDER HAD SEVERE TISSUE DAMAGE AND INTERNAL BLEEDING. USER WAS HOSPITALIZED FOR 3 DAYS. NO MALFUNCTION OF THE PRODUCT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    596128 POWERED WHEELCHAIR 890.3860 ITI INVACARE TAYLOR STREET 3GTQSP

    Patients

    Seq Age Sex Outcome Treatment
    1 Hospitalization| O| R