BEUDAMED
    FDA Adverse Event Other Summary report: N

    PRIDE

    MDR report key: 533132 · Received July 2, 2004

    Report

    Report Number
    2530130-2004-00010
    Event Type
    Other
    Date Received
    July 2, 2004
    Date of Event
    May 2, 2004
    Report Date
    June 30, 2004
    Manufacturer
    PRIDE MOBILITY PRODUCTS
    Product Code
    INI
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    FL, US
    Reporter Occupation
    UNKNOWN

    Narratives

    Description of Event or Problem · 1

    THE END USER WAS DRIVING THE UNIT WHEN USER BECAME STUCK IN MUD. USER GOT OUT OF THE UNIT AND TRIED TO PUSH THE UNIT BY THE ARM WHEN THE ARM BROKE OFF THE UNIT. THE END USER FELL AND SUSTAINED A FRACTURED LEFT HIP.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 PRIDE JAZZY INI PRIDE MOBILITY PRODUCTS JET 3 ULTRA NA

    Patients

    Seq Age Sex Outcome Treatment
    1 69 YR Hospitalization| O