BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    IDENTITY ADX DR

    MDR report key: 4143219 · Received January 13, 2014

    Report

    Report Number
    2017865-2014-05689
    Event Type
    Malfunction
    Date Received
    January 13, 2014
    Date of Event
    July 13, 2012
    Manufacturer
    ST. JUDE MEDICAL, INC. CRMD
    Product Code
    DXY
    PMA / PMN Number
    NA
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    US
    Reporter Occupation
    NURSE

    Narratives

    Additional Manufacturer Narrative · 1

    ALL INFORMATION PROVIDED BY MANUFACTURER, NO MEDWATCH FORM WAS RECEIVED. THIS HISTORICAL COMPLAINT IS BEING FILED AS PART OF A RETROSPECTIVE REVIEW OF COMPLAINT FILES IN RESPONSE TO A RECENT FDA INSPECTION. THERE IS NO CHANGE TO THE ACTUAL PERFORMANCE OF THE PRODUCT AND THIS REPORT ONLY REPRESENTS AN ENHANCEMENT TO THE REPORTING CRITERIA GOING FORWARD.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT DURING A FOLLOW UP THE DEVICE PRESENTED IN BACK UP MODE. DUE TO NORMAL ERI THE DEVICE WAS SCHEDULE TO EXPLANTED AND REPLACED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    31922 IDENTITY ADX DR IMPLANTABLE PACEMAKER PULSE GENERATOR DXY ST. JUDE MEDICAL, INC. CRMD 5380

    Patients

    Seq Age Sex Outcome Treatment
    1 76 YR