BEUDAMED
    FDA Adverse Event Other Summary report: N

    ALLEGIANCE

    MDR report key: 560244 · Received December 15, 2004

    Report

    Report Number
    2433012-2004-00001
    Event Type
    Other
    Date Received
    December 15, 2004
    Date of Event
    October 25, 2004
    Report Date
    December 14, 2004
    Manufacturer
    BUSSE HOSPITAL DISPOSABLES, INC.
    Product Code
    EBR
    Report Source
    Manufacturer report
    Reporter Location
    ND, US
    Reporter Occupation
    NURSE

    Narratives

    Description of Event or Problem · 1

    DISCOVERED THE TIP OF THE POOLE SUCTION INSTRUMENT TO BE BROKEN AFTER REMOVING SUCTION FROM PATIENTS ABDOMEN. PT WAS UNDERGOING ABDOMINAL SURGERY FOR PERFORATED STOMACH ULCER.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 ALLEGIANCE POOLE SUCTION INSTRUMENT EBR BUSSE HOSPITAL DISPOSABLES, INC. K770 0420429D

    Patients

    Seq Age Sex Outcome Treatment
    1 * Other