Brand Name | ENDURANCE QUAD CANE |
Type of Device | QUAD CANE |
Manufacturer (Section D) |
COM-BRIDGE INTERNATIONAL CO. LTD. |
unit 1, no. 66, yulong 3 road |
dong sheng town |
zhong shan city, guangdong, 52841 4 |
CH 528414 |
|
MDR Report Key | 15808799 |
MDR Text Key | 303800261 |
Report Number | 1056127-2022-00013 |
Device Sequence Number | 1 |
Product Code |
IPS
|
UDI-Device Identifier | 00754756913206 |
UDI-Public | 754756913206 |
Combination Product (y/n) | N |
Reporter Country Code | US |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Distributor
|
Reporter Occupation |
Other
|
Type of Report
| Initial |
Report Date |
11/16/2022,10/19/2022 |
1 Device was Involved in the Event |
|
1 Patient was Involved in the Event |
|
Is this an Adverse Event Report? |
No
|
Is this a Product Problem Report? |
Yes
|
Device Operator |
Lay User/Patient
|
Device Model Number | ST802-CBL |
Device Catalogue Number | W1302BL |
Was Device Available for Evaluation? |
Yes
|
Was the Report Sent to FDA? |
Yes
|
Date Report Sent to FDA | 11/16/2022 |
Distributor Facility Aware Date | 10/19/2022 |
Device Age | 8 MO |
Event Location |
Other
|
Date Report to Manufacturer | 11/08/2022 |
Initial Date Manufacturer Received |
Not provided
|
Initial Date FDA Received | 11/16/2022 |
Is This a Reprocessed and Reused Single-Use Device? |
No
|
Patient Sequence Number | 1 |
Patient Age | 62 YR |
Patient Sex | Male |
Patient Weight | 113 KG |
Patient Ethnicity | Non Hispanic |
Patient Race | White |
|
|