Brand Name | RESOLUTION 360 CLIP |
Type of Device | HEMOSTATIC METAL CLIP FOR THE GI TRACT |
Manufacturer (Section D) |
BOSTON SCIENTIFIC CORPORATION |
300 boston scientific way |
marlborough MA 01752 |
|
Manufacturer (Section G) |
BOSTON SCIENTIFIC CORPORATION |
2546 calle primera |
|
alajuela |
CS
|
|
Manufacturer Contact |
carole
morley
|
300 boston scientific way |
marlborough, MA 01752
|
5086834015
|
|
MDR Report Key | 16677226 |
MDR Text Key | 313162669 |
Report Number | 3005099803-2023-01715 |
Device Sequence Number | 1 |
Product Code |
PKL
|
UDI-Device Identifier | 08714729875635 |
UDI-Public | 08714729875635 |
Combination Product (y/n) | N |
Reporter Country Code | US |
PMA/PMN Number | K222503 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
Health Professional,User Facility,Company Representative |
Reporter Occupation |
Risk Manager
|
Type of Report
| Initial |
Report Date |
04/04/2023 |
1 Device was Involved in the Event |
|
1 Patient was Involved in the Event |
|
Date FDA Received | 04/04/2023 |
Is this an Adverse Event Report? |
No
|
Is this a Product Problem Report? |
Yes
|
Device Operator |
Health Professional
|
Device Model Number | M00521231 |
Device Catalogue Number | 54773 |
Device Lot Number | 0029560756 |
Was Device Available for Evaluation? |
No
|
Is the Reporter a Health Professional? |
No
|
Date Manufacturer Received | 03/13/2023 |
Was Device Evaluated by Manufacturer? |
Device Not Returned to Manufacturer
|
Date Device Manufactured | 06/09/2022 |
Is the Device Single Use? |
Yes
|
Type of Device Usage |
Unknown
|
Patient Sequence Number | 1 |
Patient Age | 48 YR |
Patient Sex | Male |
Patient Weight | 99 KG |