BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    NITE GUARD

    MDR report key: 4128563 · Received May 1, 2014

    Report

    Report Number
    1825660-2014-00771
    Event Type
    Malfunction
    Date Received
    May 1, 2014
    Date of Event
    January 27, 2014
    Report Date
    April 30, 2014
    Manufacturer
    RANIR CORPORATION
    Product Code
    OBR
    PMA / PMN Number
    K091792
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    MI, US
    Reporter Occupation
    NOT APPLICABLE

    Narratives

    Additional Manufacturer Narrative · 1

    THIS EVENT HAPPENED IN (B)(6). THIS COMPLAINT HAS NOT BEEN CONFIRMED. DEVICE NOT RETURNED TO MANUFACTURER, AND NO LOT NUMBER INFORMATION WAS GIVEN SO AN EVALUATION CANNOT BE PERFORMED AS TO THE ROOT CAUSE OR ACTUAL NATURE OF THE PROBLEM. NO INJURY WAS REPORTED, NO MEDICAL ATTENTION WAS REPORTED TO HAVE BEEN SOUGHT. THIS IS BEING REPORTED AS A POSSIBLE DELAMINATION, AS CHOKING IS POSSIBLE AS A RESULT OF DELAMINATION.

    Description of Event or Problem · 1

    HE USED IT AND FOLLOWED THE DIRECTIONS AND THE PRODUCT FELL APART. AFTER HE PLACED IT IN THE HOT WATER FOR ABOUT 30 MINUTES AS IN THE INSTRUCTIONS, THAT'S WHEN IT FELL APART AND HE WASN'T ABLE TO MAKE AN IMPRESSION OR USE IT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    263299 NITE GUARD MOUTHGUARD, OVER THE COUNTER OBR RANIR CORPORATION GEN II ORIG

    Patients

    Seq Age Sex Outcome Treatment
    1 Life Threatening