BEUDAMED
    FDA Adverse Event Injury Summary report: N

    PRECISION

    MDR report key: 9508088 · Received December 20, 2019

    Report

    Report Number
    3006630150-2019-07585
    Event Type
    Injury
    Date Received
    December 20, 2019
    Date of Event
    January 1, 2016
    Report Date
    December 20, 2019
    Manufacturer
    BOSTON SCIENTIFIC NEUROMODULATION
    Product Code
    LGW
    PMA / PMN Number
    P030017
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    IN, US
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 1

    THE EXACT DATE OF THE EVENT IS UNKNOWN. THE PROVIDED EVENT DATE (B)(6) 2016 WAS CHOSEN AS A BEST ESTIMATE BASED ON THE DATE THAT THE MANUFACTURER BECAME AWARE OF THE EVENT. EXPLANT DATE: 2016. MODEL NUMBER/CATALOG NUMBER: SC-2138-50. SERIAL NUMBER: (B)(4). BATCH/LOT NUMBER: A17619. MODEL/CATALOG DESCRIPTION: PHASE III LINEAR LEAD 50CM. MODEL NUMBER/CATALOG NUMBER: SC-2138-70. SERIAL NUMBER: (B)(4). BATCH/LOT NUMBER: 142319. MODEL/CATALOG DESCRIPTION: PHASE III LINEAR LEAD 70CM. THE EXPLANTED DEVICES WERE NOT RETURNED TO BSN AS THEY WERE DISCARDED BY THE MEDICAL FACILITY. A REVIEW OF THE MANUFACTURING DOCUMENTATION FOR THE IPG AND LEADS REVEALED THAT NO ANOMALIES OR DEVIATIONS POTENTIALLY RELATED TO THE EVENT OCCURRED DURING MANUFACTURING.

    Description of Event or Problem · 1

    A REPORT WAS RECEIVED THAT THE PATIENT UNDERWENT AN EXPLANT PROCEDURE FOR AN UNKNOWN REASON. NO FURTHER INFORMATION COULD BE OBTAINED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1296267 PRECISION STIMULATOR, SPINAL-CORD, TOTALLY IMPLANTED FOR PAIN RELIEF LGW BOSTON SCIENTIFIC NEUROMODULATION SC-1110 164467

    Patients

    Seq Age Sex Outcome Treatment
    1 58 YR Required Intervention