Brand Name | AG-920RA |
Type of Device | MULTI-GAS UNIT |
Manufacturer (Section D) |
NIHON KOHDEN CORPORATION |
1-31-4 nishiochia, shinjuku-ku |
attn: shama mooman |
tokyo, japan 161-8 560 |
JA 161-8560 |
|
Manufacturer (Section G) |
NIHON KOHDEN TOMIOKA CORPORATION |
1-1 tajino |
attn: shama mooman |
gunma 370-2 314 |
JA
370-2314
|
|
Manufacturer Contact |
shama
mooman
|
safety mgmt dept, quality mgmt |
seibu bldg 2, 4th floor 1-11-2 |
kusunokidai tokorozawa, saitama 359-8-580
|
JA
359-8580
|
2687488
|
|
MDR Report Key | 6165508 |
MDR Text Key | 62384620 |
Report Number | 8030229-2016-00554 |
Device Sequence Number | 1 |
Product Code |
CCK
|
Combination Product (y/n) | N |
Reporter Country Code | US |
PMA/PMN Number | K020046 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
user facility |
Reporter Occupation |
Biomedical Engineer
|
Type of Report
| Initial,Followup |
Report Date |
12/10/2016,11/10/2016 |
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 Model Number | AG-920RA |
Device Catalogue Number | AG-920RA |
Was Device Available for Evaluation? |
Device Returned to Manufacturer
|
Date Returned to Manufacturer | 11/15/2016 |
Is the Reporter a Health Professional? |
Yes
|
Was the Report Sent to FDA? |
Yes
|
Date Report Sent to FDA | 12/10/2016 |
Distributor Facility Aware Date | 11/10/2016 |
Device Age | 128 MO |
Event Location |
Hospital
|
Date Report to Manufacturer | 12/10/2016 |
Initial Date Manufacturer Received |
12/10/2016 |
Initial Date FDA Received | 12/11/2016 |
Supplement Dates Manufacturer Received | Not provided
|
Supplement Dates FDA Received | 04/11/2017
|
Was Device Evaluated by Manufacturer? |
Yes
|
Date Device Manufactured | 03/08/2006 |
Is the Device Single Use? |
No
|
Is This a Reprocessed and Reused Single-Use Device? |
No
|
Type of Device Usage |
Reuse
|
Patient Sequence Number | 1 |
|
|