MAUDE Adverse Event Report: UNKNOWN MECHANICAL WALKER, ROLLATOR; 890.3825

Model Number 65650R

Device Problem Break (1069)

Patient Problems Bruise/Contusion (1754); Fall (1848); Skin Tears (2516)

Event Type  No Answer Provided  

Event Description

Dealer stated end user was walking towards kitchen when the right rear caster on her 65650r rollator broke, angled outward.User fell and hit a cabinet, sustained several cuts and bruises.

• Brand Name: MECHANICAL WALKER, ROLLATOR
• Type of Device: 890.3825
• Manufacturer (Section D): UNKNOWN; OH
• MDR Report Key: 4165795
• MDR Text Key: 4768222
• Report Number: 1531186-2014-04832
• Device Sequence Number: 1
• Product Code: ITJ
• Combination Product (y/n): N
• Reporter Country Code: US
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Invalid Data
• Reporter Occupation: Medical Equipment Company Technician/Representative
• Type of Report: Initial
• Report Date: 10/10/2014,09/30/2014

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Device Operator: Lay User/Patient
• Device Model Number: 65650R
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Was the Report Sent to FDA?: Yes
• Date Report Sent to FDA: 10/10/2014
• Distributor Facility Aware Date: 09/30/2014
• Date Report to Manufacturer: 10/10/2014
• Initial Date Manufacturer Received: Not provided
• Initial Date FDA Received: 10/13/2014
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1
• Patient Outcome(s): Other