MAUDE Adverse Event Report: BELMONT MEDICAL TECHNOLOGIES ALLON; THERMAL REGULATING SYSTEM

Model Number	ALLON 2001
Medical Device Problem Code	Infusion or Flow Problem (2964)
Health Effect - Clinical Code	No Information (3190)
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The allon has not been returned to belmont for evaluation.We have reached out to the distributor to request that the unit be returned for investigation.The operator's manual provides a detailed troubleshooting guide, including potential causes of a problem and the action to be taken.Without additional information, it is difficult to determine what occurred in this case at this time.We will continue to follow up with the distributor to obtain additional details about the case.No patient injury was reported.Should additional information become available, a supplemental report will be submitted.
Event or Problem Description
The user facility reported that there was no water flow while using the allon.

• Brand Name: ALLON
• Common Device Name: THERMAL REGULATING SYSTEM
• Manufacturer (Section D): BELMONT MEDICAL TECHNOLOGIES; 780 boston road; billerica, ma
• MDR Report Key: 10019824
• Report Number: 1219702-2020-00036
• Device Sequence Number: 14314714
• Product Code: DWJ
• UDI-Device Identifier: 07290107581103
• UDI-Public: 07290107581103
• Combination Product (Y/N): N
• Initial Reporter Country: CA
• PMA/510(K) Number: K024128
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: distributor,user facility
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 05/03/2020

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
• Operator of Device: Health Professional
• Device Model Number: ALLON 2001
• Device Catalogue Number: 100-00001
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 04/03/2020
• Initial Report FDA Received Date: 05/03/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1