Brand Name | LIBERTY CYCLER |
Type of Device | SYSTEM, PERITONEAL, AUTOMATIC DELIVERY |
Manufacturer (Section D) |
CONCORD MANUFACTURING |
4040 nelson avenue |
concord CA 94520 |
|
Manufacturer (Section G) |
CONCORD MANUFACTURING |
4040 nelson avenue |
|
concord CA 94520 |
|
Manufacturer Contact |
thomas
c. johnson
|
920 winter st. |
waltham, MA 02451
|
7816999499
|
|
MDR Report Key | 6749521 |
MDR Text Key | 81235017 |
Report Number | 2937457-2017-00642 |
Device Sequence Number | 1 |
Product Code |
FKX
|
UDI-Device Identifier | 00840861100972 |
UDI-Public | 00840861100972 |
Combination Product (y/n) | N |
Reporter Country Code | US |
PMA/PMN Number | K123630 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
consumer,health professional |
Reporter Occupation |
Patient
|
Type of Report
| Initial |
Report Date |
07/27/2017 |
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 Operator |
Lay User/Patient
|
Device Catalogue Number | RTLR180111 |
Was Device Available for Evaluation? |
Yes
|
Is the Reporter a Health Professional? |
No
|
Device Age | MO |
Initial Date Manufacturer Received |
06/30/2017 |
Initial Date FDA Received | 07/27/2017 |
Was Device Evaluated by Manufacturer? |
No
|
Date Device Manufactured | 12/09/2008 |
Is the Device Single Use? |
No
|
Is This a Reprocessed and Reused Single-Use Device? |
No
|
Type of Device Usage |
Reuse
|
Patient Sequence Number | 1 |
Treatment | INSULIN; LASIX; LIBERTY CYCLER SET; PD FLUID |
Patient Outcome(s) |
Hospitalization;
Required Intervention;
|
Patient Age | 68 YR |