Brand Name | HOME HEMO COMBI SET |
Type of Device | SET, TUBING, BLOOD, WITH AND WITHOUT ANTI-REGURGITATION VALVE |
Manufacturer (Section D) |
ERIKA DE REYNOSA, S.A. DE C.V. |
mike allen #1331 |
parque industrial reynosa |
reynosa 88780 |
MX 88780 |
|
Manufacturer (Section G) |
ERIKA DE REYNOSA, S.A. DE C.V. |
mike allen #1331 |
parque industrial reynosa |
reynosa 88780 |
MX
88780
|
|
Manufacturer Contact |
thomas c.
johnson
|
920 winter st. |
waltham, MA 02451
|
7816999499
|
|
MDR Report Key | 6572469 |
MDR Text Key | 75385174 |
Report Number | 8030665-2017-00248 |
Device Sequence Number | 1 |
Product Code |
FJK
|
Combination Product (y/n) | N |
Reporter Country Code | US |
PMA/PMN Number | K070049 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
company representative,health |
Reporter Occupation |
Other Health Care Professional
|
Type of Report
| Initial |
Report Date |
05/17/2017 |
1 Device was Involved in the Event |
|
1 Patient was Involved in the Event |
|
Date FDA Received | 05/17/2017 |
Is this an Adverse Event Report? |
No
|
Is this a Product Problem Report? |
Yes
|
Device Operator |
Health Professional
|
Device Expiration Date | 07/31/2019 |
Device Catalogue Number | 03-2962-3 |
Device Lot Number | 16JR01121 |
Other Device ID Number | 00840861100330 |
Was Device Available for Evaluation? |
No
|
Is the Reporter a Health Professional? |
Yes
|
Device Age | MO |
Date Manufacturer Received | 04/21/2017 |
Was Device Evaluated by Manufacturer? |
Device Not Returned to Manufacturer
|
Date Device Manufactured | 07/26/2016 |
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 |
Treatment | FRESENIUS 2008K HEMODIALYSIS MACHINE; FRESENIUS OPTIFLUX F180NRE DIALYZER FINISHED ASSY. |
Patient Age | 37 YR |
Patient Weight | 99 |