MAUDE Adverse Event Report: MEDLINE INDUSTRIES LP; ELECTRODE,ECG,STRESS,FOAM,50PK

Catalog Number	MDSM611950
Medical Device Problem Code	Appropriate Device Problem Term/Code Not Available (3191)
Health Effect - Clinical Code	Rash (2033)
Date of Event	05/14/2024
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
According to the facility on 05/14/24 the patient experienced an "intensely pruritic vesicular rash where medline ecg electrode were placed".Per the facility the location of the skin injury was "bilateral superior and posterior shoulders".Per the facility there was nothing on the skin prior to application of the electrodes.Per the facility the customer required a prescription "triamcinolone acetonide ointment and over the counter 10mg cetirizine".The sample was requested for evaluation.No additional information is available at this time.It has been determined that the reported event caused or contributed to serious injury requiring medical intervention, therefore, this medwatch is being filed.If any further relevant information is identified or obtained, a supplemental medwatch will be submitted.
Event or Problem Description
According to the facility on 05/14/24 the patient experienced an "intensely pruritic vesicular rash where medline ecg electrode were placed".

• Common Device Name: ELECTRODE,ECG,STRESS,FOAM,50PK
• Manufacturer (Section D): MEDLINE INDUSTRIES LP; three lakes drive; northfield IL 60093
• Manufacturer Contact: justin herrmann ; three lakes dr; northfield, IL 60093
• MDR Report Key: 19519440
• Report Number: 1417592-2024-00643
• Device Sequence Number: 8540810
• Product Code: DRX
• UDI-Device Identifier: 40884389830469
• UDI-Public: 40884389830469
• Combination Product (Y/N): N
• Initial Reporter State: OR
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Health Professional
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 06/12/2024

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Catalogue Number: MDSM611950
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 05/22/2024
• Initial Report FDA Received Date: 06/12/2024
• Was Device Evaluated by Manufacturer? (Y/N): No
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Unknown
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other
• Patient Age: 47 YR
• Patient Sex: Female
• Patient Weight: 61 KG