Brand Name | 21 CM (8") EXT SET W/0.2 MICRON FILTER, MICROCLAVE®, CLAMP, ROTATING LUER |
Type of Device | STOPCOCK, I.V. SET |
Manufacturer (Section D) |
ICU MEDICAL DE MEXICO, S. DE R.L. DE C.V. |
avenida cuarzo no. 250 |
ensenada, b.cfa. 22790 |
MX 22790 |
|
Manufacturer Contact |
reed
covert
|
600 n. field dr. |
lake forest, IL 60045
|
2247062300
|
|
MDR Report Key | 18211140 |
MDR Text Key | 329034600 |
Report Number | 9617594-2023-01030 |
Device Sequence Number | 1 |
Product Code |
FMG
|
UDI-Device Identifier | 00840619075675 |
UDI-Public | (01)00840619075675(17)280501(10)13643269 |
Combination Product (y/n) | N |
Reporter Country Code | FR |
PMA/PMN Number | UNKNOWN |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
Foreign,Health Professional,Company Representative |
Reporter Occupation |
Pharmacist
|
Type of Report
| Initial,Followup |
Report Date |
03/04/2024 |
1 Device was Involved in the Event |
|
1 Patient was Involved in the Event |
|
Is this an Adverse Event Report? |
No
|
Is this a Product Problem Report? |
Yes
|
Device Operator |
Health Professional
|
Device Catalogue Number | 011-H3668 |
Device Lot Number | 13643269 |
Was Device Available for Evaluation? |
Yes
|
Is the Reporter a Health Professional? |
Yes
|
Initial Date Manufacturer Received |
11/16/2023
|
Initial Date FDA Received | 11/27/2023 |
Supplement Dates Manufacturer Received | 02/06/2024
|
Supplement Dates FDA Received | 03/04/2024
|
Was Device Evaluated by Manufacturer? |
Yes
|
Date Device Manufactured | 05/01/2023 |
Is the Device Single Use? |
Yes
|
Is This a Reprocessed and Reused Single-Use Device? |
No
|
Type of Device Usage |
Initial
|
Patient Sequence Number | 1 |
Treatment | NACL 0,9% 250ML PERFUSION 1H00, MFR UNK; PEMBROLIZUMAB KEYTRUDA, MFR UNK; UNSPECIFIED INFUSION PUMP, FRESENIUS |
Patient Age | 56 YR |
|
|