Brand Name | AQUASHIELD SYSTEM CO2 - FUJINON |
Type of Device | WATER BOTTLE CAP |
Manufacturer (Section D) |
UNITED STATES ENDOSCOPY GROUP, INC. |
5976 heisley rd |
mentor OH 44060 |
|
Manufacturer (Section G) |
UNITED STATES ENDOSCOPY GROUP, INC. |
5976 heisley rd |
|
mentor OH 44060 |
|
Manufacturer Contact |
coletta
cohara
|
5976 heisley rd |
mentor, OH 44060
|
4403586251
|
|
MDR Report Key | 6817403 |
MDR Text Key | 83646215 |
Report Number | 1528319-2017-00025 |
Device Sequence Number | 1 |
Product Code |
FEQ
|
UDI-Device Identifier | 00816765013335 |
UDI-Public | (01)00816765013335(17)180604(11)170604(10)1709622 |
Combination Product (y/n) | N |
Reporter Country Code | US |
PMA/PMN Number | K163424 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
company representative,user f |
Reporter Occupation |
Other
|
Type of Report
| Initial |
Report Date |
08/24/2017 |
1 Device was Involved in the Event |
|
1 Patient was Involved in the Event |
|
Date FDA Received | 08/24/2017 |
Is this an Adverse Event Report? |
No
|
Is this a Product Problem Report? |
Yes
|
Device Operator |
Physician
|
Device Expiration Date | 06/04/2018 |
Device Model Number | 00711553 |
Device Catalogue Number | 00711553 |
Device Lot Number | 1709622 |
Was Device Available for Evaluation? |
No
|
Date Manufacturer Received | 08/04/2017 |
Was Device Evaluated by Manufacturer? |
Device Not Returned to Manufacturer
|
Date Device Manufactured | 06/04/2017 |
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;
|