BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    INTROCAN SAFETY®

    MDR report key: 6140758 · Received December 2, 2016

    Report

    Report Number
    9610825-2016-00835
    Event Type
    Malfunction
    Date Received
    December 2, 2016
    Report Date
    November 18, 2016
    Manufacturer
    B. BRAUN MELSUNGEN AG
    Product Code
    DQR
    UDI-DI
    04046963185190
    PMA / PMN Number
    K021094
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    FL, US
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL

    Narratives

    Additional Manufacturer Narrative · 0

    EXEMPTION NUMBER E2011009. B. BRAUN MEDICAL INC. IS SUBMITTING A SINGLE REPORT ON BEHALF OF B. BRAUN MELSUNGEN (THE MANUFACTURER), AND B. BRAUN MEDICAL INC. (THE IMPORTER). THIS REPORT HAS BEEN IDENTIFIED AS B. BRAUN MEDICAL INTERNAL REPORT NUMBER (B)(4). THE DEVICE INVOLVED HAS NOT BEEN RECEIVED FOR EVALUATION AND THE INVESTIGATION IS ONGOING AT THIS TIME. A FOLLOW UP WILL BE SUBMITTED WHEN THE INVESTIGATION RESULTS BECOME AVAILABLE.

    Additional Manufacturer Narrative · 0

    EXEMPTION NUMBER E2011009. B. BRAUN MEDICAL INC. IS SUBMITTING A SINGLE REPORT ON BEHALF OF B. BRAUN MELSUNGEN (THE MANUFACTURER), AND B. BRAUN MEDICAL INC. (THE IMPORTER). THIS REPORT HAS BEEN IDENTIFIED AS B. BRAUN MEDICAL INTERNAL REPORT NUMBER (B)(4). MULTIPLE UNSUCCESSFUL ATTEMPTS WERE MADE TO OBTAIN A SAMPLE AND ADDITIONAL INFORMATION. NO SAMPLE WAS RETURNED FOR EVALUATION; BECAUSE OF THIS, FURTHER INVESTIGATION OF THE COMPLAINT IS NOT POSSIBLE AND NO CONCLUSION COULD BE DRAWN. IF A SAMPLE AND/OR ANY ADDITIONAL PERTINENT INFORMATION BECOMES AVAILABLE, A FOLLOW UP WILL BE SUBMITTED. DEVICE HISTORY RECORD (DHR): REVIEW OF THE DEVICE HISTORY RECORDS WAS PERFORMED AND NO NON CONFORMANCES OR DEVIATIONS WERE NOTED IN PROCESS AND FINAL INSPECTION.

    Description of Event or Problem · 0

    AS REPORTED BY THE USER FACILITY: CUSTOMER STATED, "METAL PULLED APART WHEN BACKING OUT." LIMITED INFORMATION PROVIDED. NO INJURY. NO SAMPLE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    792426 INTROCAN SAFETY® I.V. SAFETY CATHETER DQR B. BRAUN MELSUNGEN AG 16F14G8304 04046963185190

    Patients

    Seq Age Sex Outcome Treatment
    1