Brand Name | IV ADMINISTRATION SET |
Type of Device | SET, ADMINISTRATION, INTRA |
Manufacturer (Section D) |
B. BRAUN MEDICAL INC. |
901 marcon blvd. |
allentown PA 18109 |
|
Manufacturer (Section G) |
B. BRAUN DOMINICIAN REPULIC INC. |
las americas industrial park |
km22 autopista las americas |
santo domingo |
DR
|
|
Manufacturer Contact |
jonathan
severino
|
901 marcon blvd. |
allentown, PA 18109
|
4847197287
|
|
MDR Report Key | 12862329 |
MDR Text Key | 281212454 |
Report Number | 2523676-2021-00394 |
Device Sequence Number | 1 |
Product Code |
FPA
|
UDI-Device Identifier | 04046964188176 |
UDI-Public | (01)04046964188176 |
Combination Product (y/n) | N |
Reporter Country Code | CA |
PMA/PMN Number | K173361 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
Foreign,User Facility,Distributor |
Reporter Occupation |
Other Health Care Professional
|
Type of Report
| Initial,Followup |
Report Date |
01/28/2022 |
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 | V1390 |
Device Catalogue Number | V1390 |
Device Lot Number | 0061765291 |
Was Device Available for Evaluation? |
No
|
Is the Reporter a Health Professional? |
Yes
|
Initial Date Manufacturer Received |
11/09/2021 |
Initial Date FDA Received | 11/23/2021 |
Supplement Dates Manufacturer Received | 11/09/2021
|
Supplement Dates FDA Received | 01/28/2022
|
Was Device Evaluated by Manufacturer? |
Device Not Returned to Manufacturer
|
Date Device Manufactured | 01/29/2021 |
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 |