BEUDAMED
    FDA Adverse Event Injury Summary report: N

    UCENTUM

    MDR report key: 6657815 · Received June 21, 2017

    Report

    Report Number
    9612420-2017-00018
    Event Type
    Injury
    Date Received
    June 21, 2017
    Date of Event
    May 23, 2017
    Report Date
    June 21, 2017
    Manufacturer
    ULRICH GMBH & CO. KG
    Product Code
    NKB
    PMA / PMN Number
    K123717
    Removal / Correction Number
    NA
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    AR, US
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 0

    ULRICH MEDICAL GMBH (MANUFACTURER) IS SUBMITTING THIS REPORT FOR BOTH ULRICH MEDICAL GMBH AND ULRICH MEDICAL USA (IMPORTER) EXEMPTION # E2014011

    Description of Event or Problem · 0

    SCREW BREAKAGE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    438536 UCENTUM SCREW, POLYAXIAL, 7.5MM, LENGTH 50MM NKB ULRICH GMBH & CO. KG CS 3802-XXX-XXX UNKNOWN

    Patients

    Seq Age Sex Outcome Treatment
    1 Required Intervention