MAUDE Adverse Event Report: ZHENJIANG ASSURE MEDICAL EQUIPMENT CO. LTD. WALGREENS TRANSPORT CHAIRS/WHEELCHAIRS TRANSPORT CHAIRS; CHAIR, WITH CASTERS

Model Number	783179
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	Laceration(s) (1946)
Date of Event	05/13/2026
Type of Reportable Event	Serious Injury
Event or Problem Description
Drive medical was notified of an incident involving a transport wheelchair by the end user's spouse who reported the chair frame broke during use, the end user fell and received a laceration on his head requiring four stitches and an overnight stay in the hospital.As part of its complaint review and evaluation process, drive medical will also notify the manufacturer of the product about this complaint.

• Brand Name: WALGREENS TRANSPORT CHAIRS/WHEELCHAIRS TRANSPORT CHAIRS
• Common Device Name: CHAIR, WITH CASTERS
• Manufacturer (Section D): ZHENJIANG ASSURE MEDICAL EQUIPMENT CO. LTD.; no 297,chuqiao road,; zhenjiang city, jiangsu ; CH
• MDR Report Key: 25635910
• Report Number: 2438477-2026-00038
• Device Sequence Number: 15886933
• Product Code: INM
• UDI-Device Identifier: 00311917203157
• UDI-Public: (01)00311917203157
• Combination Product (Y/N): N
• Initial Reporter State: TN
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Importer
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 06/26/2026
• Report Date (Section F): 06/26/2026

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?: Yes
• Operator of Device: Lay User/Patient
• Device Model Number: 783179
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: Yes
• Distributor Facility Aware Date: 06/05/2026
• Device Age: 2 YR
• Event Location: Home
• Date Report to Manufacturer: 06/26/2026
• Initial Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 06/26/2026
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Required Intervention; Hospitalization
• Patient Age: 76 YR
• Patient Sex: Unknown
• Patient Weight: 93 KG
• Date Report Sent to FDA: 06/26/2026