Brand Name | PROCLAIM 5 ELITE |
Type of Device | SCS IPG |
Manufacturer (Section D) |
ST. JUDE MEDICAL - NEUROMODULATION |
6901 preston rd |
plano TX 75024 |
|
Manufacturer (Section G) |
ST. JUDE MEDICAL - NEUROMODULATION |
6901 preston rd |
|
plano TX 75024 |
|
MDR Report Key | 7554148 |
MDR Text Key | 109561560 |
Report Number | 1627487-2018-05300 |
Device Sequence Number | 1 |
Product Code |
LGW
|
Combination Product (y/n) | N |
Reporter Country Code | US |
PMA/PMN Number | P010032 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
company representative,consum |
Reporter Occupation |
Other
|
Remedial Action |
Other |
Type of Report
| Initial,Followup |
Report Date |
03/21/2019 |
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 |
Health Professional
|
Device Expiration Date | 02/07/2019 |
Device Model Number | 3660 |
Device Lot Number | 5841550 |
Other Device ID Number | 05415067020192 |
Was Device Available for Evaluation? |
No
|
Is the Reporter a Health Professional? |
No
|
Was the Report Sent to FDA? |
No
|
Initial Date Manufacturer Received |
05/17/2018 |
Initial Date FDA Received | 05/30/2018 |
Supplement Dates Manufacturer Received | 03/18/2019
|
Supplement Dates FDA Received | 03/21/2019
|
Was Device Evaluated by Manufacturer? |
No
|
Date Device Manufactured | 02/07/2017 |
Is the Device Single Use? |
Yes
|
Is This a Reprocessed and Reused Single-Use Device? |
No
|
Type of Device Usage |
Initial
|
Removal/Correction Number | 1627487-060217-001-C |
Patient Sequence Number | 1 |
Treatment | MODEL 1192 (2), SCS ANCHOR; MODEL 3186 (2), SCS LEAD |
Patient Outcome(s) |
Other;
|
Patient Age | 65 YR |
|
|