FDA Adverse Event Injury Summary report: N

UMI LARGE BALLOON CATHETER INTRODUCER SET

MDR report key: 5396 · Received March 15, 1993

Report

Report Number
5396
Event Type
Injury
Date Received
March 15, 1993
Date of Event
February 4, 1993
Report Date
February 24, 1993
Manufacturer
UNIVERSAL MEDICAL INSTRUMENT CORP
Product Code
DYB
Adverse Event
Yes
Report Source
User Facility report

Narratives

Description of Event or Problem · 1

PATIENT HAD CARDIAC CATH IN LAB AT WHICH TIME INTRODUCER WAS INSERTED. AFTER THE PATIENT HAD LEFT THE CATH LAB, IT WAS FOUND THAT THE DIAPHRAM END OF INTRODUCER HAD BECOME DISCONNECTED. IT APPEARED THE BOND HAD COME LOOSE. PATIENT BEGAN TO HEMORRHAGE. PATIENT WAS RETURNED TO CATH LAB DUE TO INCREASED CHEST PAIN AFTER BLEEDING CONTROLLED. PATIENT WENT ON TO HAVE AN M.I.DEVICE LABELED FOR SINGLE USE. PATIENT MEDICAL STATUS PRIOR TO EVENT: SATISFACTORY CONDITION. THERE WAS NOT MULTIPLE PATIENT INVOLVEMENT.INVALID DATA - ON DEVICE SERVICE/MAINTENANCE. NO DATA - REGARDING DATE LAST SERVICED. SERVICE PROVIDED BY: INVALID DATA. INVALID DATA - SERVICE RECORDS AVAILABILITY. INVALID DATA - REGARDING WHETHER EVENT PRESENTS IMMINENT HAZARD. DEVICE USED AS LABELED/INTENDED.DEVICE WAS EVALUATED AFTER THE EVENT. METHOD OF EVALUATION: VISUAL EXAMINATION. RESULTS OF EVALUATION: COMPONENT FAILURE, NONE OR UNKNOWN, HUB. CONCLUSION: DEVICE FAILURE DIRECTLY CAUSED EVENT. CERTAINTY OF DEVICE AS CAUSE OF OR CONTRIBUTOR TO EVENT: YES. CORRECTIVE ACTIONS: DEVICE PERMANENTLY REMOVED FROM SERVICE. THE DEVICE WAS NOT DESTROYED/DISPOSED OF.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 UMI LARGE BALLOON CATHETER INTRODUCER SET CATH SEAL - PCI W/3 WAY STOP COCK DYB UNIVERSAL MEDICAL INSTRUMENT CORP 150393

Patients

Seq Age Sex Outcome Treatment
1 60 YR Required Intervention