Type of Device | CLIP, IMPLANTABLE, REPROCESSED |
Manufacturer (Section D) |
STERILMED, INC. |
11400 73rd ave n |
maple grove MN |
|
Manufacturer Contact |
jason
anderson
|
5010 cheshire parkway |
suite 2 |
plymouth, MN 55446
|
7635888348
|
|
MDR Report Key | 5625466 |
MDR Text Key | 44243336 |
Report Number | 2134070-2016-00025 |
Device Sequence Number | 1 |
Product Code |
NMJ
|
Combination Product (y/n) | N |
Reporter Country Code | US |
PMA/PMN Number | K033579 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
company representative,health |
Reporter Occupation |
Health Professional
|
Type of Report
| Initial,Followup |
Report Date |
04/07/2016 |
1 Device was Involved in the Event |
|
1 Patient was Involved in the Event |
|
Date FDA Received | 05/03/2016 |
Is this an Adverse Event Report? |
Yes
|
Is this a Product Problem Report? |
Yes
|
Device Operator |
Health Professional
|
Device Expiration Date | 10/30/2016 |
Device Model Number | ETHER320 |
Device Catalogue Number | ETHER320 |
Device Lot Number | 1905374 |
Was Device Available for Evaluation? |
Device Returned to Manufacturer
|
Date Returned to Manufacturer | 05/23/2016 |
Is the Reporter a Health Professional? |
Yes
|
Date Manufacturer Received | 05/23/2016 |
Was Device Evaluated by Manufacturer? |
Yes
|
Date Device Manufactured | 10/30/2015 |
Is the Device Single Use? |
Yes
|
Is This a Reprocessed and Reused Single-Use Device? |
Yes
|
Type of Device Usage |
Initial
|
Patient Sequence Number | 1 |
Patient Outcome(s) |
Required Intervention;
|
Patient Age | 38 YR |
Patient Weight | 138 |
|
|