BEUDAMED
    FDA Adverse Event Injury Summary report: N

    LIFE GASE

    MDR report key: 5402197 · Received January 28, 2005

    Report

    Report Number
    5402197
    Event Type
    Injury
    Date Received
    January 28, 2005
    Date of Event
    January 12, 2005
    Report Date
    January 19, 2005
    Manufacturer
    LIFE GAS LLC
    Product Code
    CAN
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    User Facility report
    Reporter Location
    IL, US
    Reporter Occupation
    0

    Narratives

    Description of Event or Problem · 1

    VALVE REGULATOR ON SMALL OXYGEN TANK FAILED CAUSING TANK TO DAMAGE BED PT WAS IN. RESIDENT BUMPED HEAD ON NIGHTSTAND. PT SENT TO ER FOR SAFETY AND RETURNED TO FACILITY. OXYGEN TANK VENDOR CONDUCTING INVESTIGATION. TANK WAS NOT IN USE WHEN VALVE DISENGAGED. THIS INCIDENT CAUSED PT TO FALL OUT OF BED. MFR # 3003900188-2005-00001.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 LIFE GASE WALK ABOUT OXYGEN TANK CAN LIFE GAS LLC USP UN 1072

    Patients

    Seq Age Sex Outcome Treatment
    1 81 YR Hospitalization