BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    LUMEX BED SOCKET TELESCOPING IV POLE

    MDR report key: 5191045 · Received October 30, 2015

    Report

    Report Number
    5191045
    Event Type
    Malfunction
    Date Received
    October 30, 2015
    Date of Event
    October 7, 2015
    Report Date
    October 20, 2015
    Manufacturer
    GENTRY HARDWARE PRODUCTS CO., LTD.
    Product Code
    FOX
    Adverse Event
    Yes
    Report Source
    User Facility report
    Reporter Location
    NV, US
    Reporter Occupation
    OTHER

    Narratives

    Description of Event or Problem · 1

    IV POLE BROKE AT THE BOTTOM AND CAUSED PUMP TO FALL TO THE FLOOR AND PATIENT'S CENTRAL LINE TO COME OUT OF PLACE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    720808 LUMEX BED SOCKET TELESCOPING IV POLE STAND, INFUSION FOX GENTRY HARDWARE PRODUCTS CO., LTD. 2100A P071205

    Patients

    Seq Age Sex Outcome Treatment
    1 51 YR LUMEX IV POLE WITH A BRAIN AND TWO CASSETTES ATTAC