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Who was operating the device? Customer - Healthcare Professional Customer - BMET / Clinical Engineer Customer - Other Verathon - Sales / Clinical Speciallist Verathon - Internal / Other Distributor Regulatory Body Media Other
Date incident occurred
Complaint Description Please include device problem(s), details of what happened, troubleshooting, & additional information requested.
Device Type GlideScope BladderScan
Device Model
Part Number (1)
Serial / Lot Number (1)
Part Description (1)
Part Number (2)
Serial / Lot Number (2)
Part Description (2)
Part Number (3)
Serial / Lot Number (3)
Part Description (3)
When was the malfunction identified? Unknown Other Inspection Cleaning Setup Patient Procedure Unknown = Unsure when issue occurred || Other = Description listed do not fit when issue was found || Inspection = Discovered during routine preventable maintenance || Cleaning = Discovered during cleaning || Setup = Discovered before procedure took place while setting up || Patient Procedure = Problem was identified while already in-use on patient
Was there report of patient or user injury? YesNo
Was there report of patient or user death? YesNo
If identified during patient procedure did it occur during an emergency care resulting in delayed treatment? YesNo
Was there report of medical intervention due to the complaint event? YesNo
If yes, describe the intervention due to complaint
If identified during a patient procedure is information such as identifier number, age, weight, gender available? YesNo
If identified during patient procedure was a backup device used in order to complete the procedure? YesNo
Is the product being returned to Verathon? YesNo
Comments