Brand Name | RENEGADE HI-FLO FATHOM SYSTEM |
Type of Device | CATHETER, CONTINUOUS FLUSH |
Manufacturer (Section D) |
BOSTON SCIENTIFIC CORPORATION |
two scimed place |
maple grove MN 55311 |
|
Manufacturer (Section G) |
BOSTON SCIENTIFIC CORK LIMITED |
model farm road |
|
cork |
EI
|
|
Manufacturer Contact |
jay
johnson
|
two scimed place |
maple grove, MN 55311
|
7634942574
|
|
MDR Report Key | 10455120 |
MDR Text Key | 204402529 |
Report Number | 2134265-2020-11672 |
Device Sequence Number | 1 |
Product Code |
KRA
|
UDI-Device Identifier | 08714729790860 |
UDI-Public | 08714729790860 |
Combination Product (y/n) | N |
Reporter Country Code | CH |
PMA/PMN Number | K140329 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
company representative,distri |
Reporter Occupation |
Physician
|
Type of Report
| Initial |
Report Date |
08/26/2020 |
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
|
Device Operator |
Health Professional
|
Device Expiration Date | 03/31/2020 |
Device Model Number | 29462 |
Device Catalogue Number | 29462 |
Device Lot Number | 0020469248 |
Was Device Available for Evaluation? |
No
|
Is the Reporter a Health Professional? |
Yes
|
Initial Date Manufacturer Received |
08/05/2020 |
Initial Date FDA Received | 08/26/2020 |
Was Device Evaluated by Manufacturer? |
Device Not Returned to Manufacturer
|
Date Device Manufactured | 04/06/2017 |
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 Age | 38 YR |
Patient Weight | 52 |