MAUDE Adverse Event Report: UNKNOWN NARROW BASE QUAD CANE 1616710022

Model Number 3920-2

Device Problem Detachment Of Device Component (1104)

Patient Problem No Consequences Or Impact To Patient (2199)

Event Type  malfunction  

Event Description

It has been reported that a (b)(4) cane was damaged; it is now in two separate pieces.

• Brand Name: NARROW BASE QUAD CANE 1616710022
• Type of Device: CANE
• Manufacturer (Section D): UNKNOWN; OH
• MDR Report Key: 4365415
• MDR Text Key: 5119419
• Report Number: 1531186-2014-06850
• Device Sequence Number: 1
• Product Code: IPS
• Combination Product (y/n): N
• Reporter Country Code: US
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Distributor
• Source Type: Invalid Data
• Reporter Occupation: Medical Equipment Company Technician/Representative
• Type of Report: Initial
• Report Date: 12/23/2014,11/13/2014

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 12/29/2014
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Lay User/Patient
• Device Model Number: 3920-2
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: Yes
• Date Report Sent to FDA: 12/23/2014
• Distributor Facility Aware Date: 11/13/2014
• Date Report to Manufacturer: 12/23/2014
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Patient Outcome(s): Other