Brand Name | ORG-9110A |
Type of Device | MULTIPLE PATIENT RECEIVER |
Manufacturer (Section D) |
NIHON KOHDEN CORPORATION |
1-31-4 nishiochia, shinjuku-ku |
attn: shama mooman |
tokyo, 161-8 560 |
JA 161-8560 |
|
Manufacturer (Section G) |
NIHON KOHDEN TOMIOKA CORPORATION |
1-1 tajino |
attn: shama mooman |
tomioka city, gunma 370-2 314 |
JA
370-2314
|
|
Manufacturer Contact |
shama
mooman
|
safety mgmt dept, quality mgmt |
seibu bldg 2, 4th floor 1-11-2 |
kusunokidai tokorozawa, saitama 359-8-580
|
JA
359-8580
|
|
MDR Report Key | 6831670 |
MDR Text Key | 84078598 |
Report Number | 8030229-2017-00284 |
Device Sequence Number | 1 |
Product Code |
DRG
|
UDI-Device Identifier | 04931921103906 |
UDI-Public | 04931921103906 |
Combination Product (y/n) | N |
Reporter Country Code | US |
PMA/PMN Number | K071058 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
user facility |
Reporter Occupation |
Biomedical Engineer
|
Type of Report
| Initial,Followup |
Report Date |
08/30/2017 |
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 | ORG-9110A |
Device Catalogue Number | ORG-9110A |
Was Device Available for Evaluation? |
No
|
Is the Reporter a Health Professional? |
Yes
|
Was the Report Sent to FDA? |
No
|
Date Report Sent to FDA | 08/30/2017 |
Distributor Facility Aware Date | 08/06/2017 |
Device Age | 53 MO |
Event Location |
Hospital
|
Date Report to Manufacturer | 08/30/2017 |
Initial Date Manufacturer Received |
08/30/2017 |
Initial Date FDA Received | 08/30/2017 |
Supplement Dates Manufacturer Received | 08/30/2017
|
Supplement Dates FDA Received | 04/17/2018
|
Was Device Evaluated by Manufacturer? |
Device Not Returned to Manufacturer
|
Date Device Manufactured | 02/28/2013 |
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 |
|
|