Brand Name | HOMECHOICE |
Type of Device | SYSTEM, PERITONEAL, AUTOMATIC DELIVERY |
Manufacturer (Section D) |
BAXTER HEALTHCARE - LARGO |
7511 114th ave. north |
largo FL 33773 |
|
Manufacturer (Section G) |
BAXTER HEALTHCARE - LARGO |
7511 114th ave. north |
|
largo FL 33773 |
|
Manufacturer Contact |
christina
arnt
|
25212 w. illinois route 120 |
round lake, IL 60073
|
2242703198
|
|
MDR Report Key | 3696592 |
MDR Text Key | 4291214 |
Report Number | 1416980-2014-09727 |
Device Sequence Number | 1 |
Product Code |
FKX
|
Combination Product (y/n) | N |
Reporter Country Code | US |
PMA/PMN Number | K102936 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
Consumer,Health Professional,Company Representative |
Reporter Occupation |
Nurse
|
Type of Report
| Initial,Followup |
Report Date |
02/27/2014 |
1 Device was Involved in the Event |
|
1 Patient was Involved in the Event |
|
Is this an Adverse Event Report? |
Yes
|
Is this a Product Problem Report? |
No
|
Device Operator |
Lay User/Patient
|
Device Catalogue Number | 5C4471R |
Was Device Available for Evaluation? |
Device Returned to Manufacturer
|
Date Returned to Manufacturer | 03/21/2014 |
Is the Reporter a Health Professional? |
Yes
|
Initial Date Manufacturer Received |
03/26/2014 |
Initial Date FDA Received | 03/24/2014 |
Supplement Dates Manufacturer Received | Not provided
|
Supplement Dates FDA Received | 04/16/2014
|
Was Device Evaluated by Manufacturer? |
Device Not Returned to Manufacturer
|
Is the Device Single Use? |
No
|
Is This a Reprocessed and Reused Single-Use Device? |
No
|
Type of Device Usage |
Reuse
|
Patient Sequence Number | 1 |
Treatment | DIANEAL PD2 1.5% AND 2.5% SOLUTIONS |
Patient Outcome(s) |
Death;
|
Patient Age | 67 YR |