MAUDE Adverse Event Report: PAJUNK GMBH MEDIZINTECHNOLOGIE STIMULONG SONO; PERIPHERAL NERVE BLOCK KIT

Model Number 521157-32A

Device Problems Partial Blockage (1065); Disconnection (1171); Fracture (1260); Improper or Incorrect Procedure or Method (2017); Device-Device Incompatibility (2919); Device Handling Problem (3265)

Patient Problems Foreign Body In Patient (2687); No Information (3190)

Event Date 11/17/2016

Event Type  malfunction  

Manufacturer Narrative

Currently the data is poor and the device has not been sent back/ analysed.As soon as further data will be available a follow up report will be sent in to the agency.

Event Description

(b)(4).Initial reporter´s narrative: disconnection of the electric wire.The electric wire is blocked at the catheter support (container?).

Manufacturer Narrative

Based on risk assessment and clinical evaluation file is considered as closed.

Event Description

(b)(4).Initial reporter´s narrative: disconnection of the electric wire.The electric wire is blocked at the catheter support (container?).

• Brand Name: STIMULONG SONO
• Type of Device: PERIPHERAL NERVE BLOCK KIT
• Manufacturer (Section D): PAJUNK GMBH MEDIZINTECHNOLOGIE; karl-hall-str. 1; geisingen, baden-wuerttemberg 78187 ; GM 78187
• Manufacturer (Section G): PAJUNK GMBH MEDIZINTECHNOLOGIE; karl-hall-str. 1; geisingen, baden-wuerttemberg 78187 ; GM 78187
• Manufacturer Contact: christian quass ; karl-hall-str. 1; regulatory & safety affairs; geisingen, baden-wuerttemberg 78187 ; GM 78187 ; 7704929158
• MDR Report Key: 6150242
• MDR Text Key: 62147517
• Report Number: 9611612-2016-00152
• Device Sequence Number: 1
• Product Code: CAZ
• UDI-Device Identifier: 04048223016268
• UDI-Public: 04048223016268
• Combination Product (y/n): N
• Reporter Country Code: FR
• PMA/PMN Number: K113188
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: distributor
• Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date: 02/16/2017

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 12/07/2016
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Device Operator: Other
• Device Expiration Date: 06/01/2021
• Device Model Number: 521157-32A
• Device Catalogue Number: 521157-32A
• Device Lot Number: 1166
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 11/30/2016
• Is the Reporter a Health Professional?: No
• Date Manufacturer Received: 11/22/2016
• Was Device Evaluated by Manufacturer?: Yes
• Date Device Manufactured: 07/01/2016
• 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
• Patient Outcome(s): Other; Required Intervention