BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    MEDSTREAM

    MDR report key: 447587 · Received March 6, 2003

    Report

    Report Number
    MW1027767
    Event Type
    Malfunction
    Date Received
    March 6, 2003
    Date of Event
    November 11, 2002
    Report Date
    March 3, 2003
    Manufacturer
    MEDICAL SPECIALTIES DISTRIBUTORS, INC.
    Product Code
    FPA
    Product Problem
    Yes
    Report Source
    Voluntary report
    Reporter Location
    OH, US
    Reporter Occupation
    ATTORNEY

    Narratives

    Description of Event or Problem · 1

    PT RECEIVING ACYCLOVIR 55 MG/8 ML OVER 1 HOUR VIA SYRINGE ATTACHED TO THE MS402 TUBING WHEN TUBING LOODKED TO BE "CORRODING" AND BECOMING SUSPENDED WITH THE IV MEDICATION. ACYCLOVIR WITH A "SPIDER WEBBING LIKE" LOOK IN TUBING.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 MEDSTREAM FLUID PATHWAY EXTENSION SET FPA MEDICAL SPECIALTIES DISTRIBUTORS, INC. MS402 B2N801

    Patients

    Seq Age Sex Outcome Treatment
    1 1 MO