Type of Device | SET, ADMINISTRATION, FOR PERITONEAL DIALYSIS, DISPOSABLE |
Manufacturer (Section D) |
BAXTER HEALTHCARE - MOUNTAIN HOME |
1900 n highway 201 |
mountain home AR 72653 |
|
Manufacturer (Section G) |
BAXTER HEALTHCARE - MOUNTAIN HOME |
1900 n highway 201 |
|
mountain home AR 72653 |
|
Manufacturer Contact |
kinga
almasan
|
25212 w. illinois route 120 |
round lake, IL 60073
|
2242702068
|
|
MDR Report Key | 5286642 |
MDR Text Key | 33197557 |
Report Number | 1416980-2015-43982 |
Device Sequence Number | 1 |
Product Code |
KDJ
|
Combination Product (y/n) | N |
Reporter Country Code | US |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
company representative,consum |
Reporter Occupation |
Other
|
Type of Report
| Initial |
Report Date |
12/10/2015 |
1 Device was Involved in the Event |
|
1 Patient was Involved in the Event |
|
Date FDA Received | 12/10/2015 |
Is this an Adverse Event Report? |
No
|
Is this a Product Problem Report? |
Yes
|
Device Operator |
Lay User/Patient
|
Was Device Available for Evaluation? |
No
|
Date Manufacturer Received | 11/19/2015 |
Is the Device Single Use? |
Yes
|
Is This a Reprocessed and Reused Single-Use Device? |
No
|
Type of Device Usage |
Unknown
|
Patient Sequence Number | 1 |
Treatment | HOMECHOICE |
Patient Age | 56 YR |
|
|