Brand Name | ST. JOHN KIT |
Type of Device | KIT, SURGICAL INSTRUMENT, DISPOSABLE |
Manufacturer (Section D) |
DEROYAL INDUSTRIES |
1501 east central ave. |
lafollette TN 37766 |
|
Manufacturer Contact |
|
200 debusk lane |
powell, TN 37849
|
8653622333
|
|
MDR Report Key | 4059582 |
MDR Text Key | 4860164 |
Report Number | 3005011024-2014-00009 |
Device Sequence Number | 1 |
Product Code |
KDD
|
Combination Product (y/n) | N |
Reporter Country Code | US |
PMA/PMN Number | EXEMPT |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
Health Professional |
Reporter Occupation |
Other
|
Type of Report
| Initial |
Report Date |
08/13/2014 |
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 |
Health Professional
|
Device Expiration Date | 07/25/2017 |
Device Catalogue Number | 77-401026 |
Device Lot Number | 35774516 |
Was Device Available for Evaluation? |
Yes
|
Date Returned to Manufacturer | 07/14/2014 |
Is the Reporter a Health Professional? |
Yes
|
Was the Report Sent to FDA? |
No
|
Distributor Facility Aware Date | 07/11/2014 |
Event Location |
Hospital
|
Initial Date Manufacturer Received |
07/11/2014 |
Initial Date FDA Received | 08/14/2014 |
Was Device Evaluated by Manufacturer? |
Yes
|
Date Device Manufactured | 04/01/2014 |
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) |
Required Intervention;
|
|
|