BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    OMNIPOD INSULIN MANAGEMENT SYSTEM

    MDR report key: 10440506 · Received August 22, 2020

    Report

    Report Number
    3004464228-2020-13484
    Event Type
    Malfunction
    Date Received
    August 22, 2020
    Date of Event
    August 19, 2020
    Report Date
    August 19, 2020
    Manufacturer
    INSULET CORPORATION
    Product Code
    LZG
    PMA / PMN Number
    K162296
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    MA, US
    Reporter Occupation
    OTHER

    Narratives

    Additional Manufacturer Narrative · 0

    THE POD WAS RECEIVED WITH THE CANNULA DEPLOYED AND NEEDLE RETRACTED. THE DOWNLOAD DATA REPORTED THAT THE DEVICE RAN 56 PULSES AND WAS DE-ACTIVATED AT THE END OF SECOND PRIME. AFTER INVESTIGATION OF THE NEEDLE MECHANISM, NO ISSUES WERE FOUND THAT WOULD RESULT IN THE NEEDLE FAILING TO RETRACT. ALTHOUGH NO PROBLEM WAS FOUND WITH THE DEVICE, IT COULD NOT BE DETERMINED WHEN THE NEEDLE RETRACTED, AND THE CAUSE OF THE REPORTED FAILURE OF THE NEEDLE TO RETRACT COULD NOT BE DETERMINED. PER NEW INFORMATION, THE FOLLOWING WERE UPDATED. D1 - BRAND NAME CHANGED FROM OMNIPOD INSULIN PUMP TO OMNIPOD INSULIN MANAGEMENT SYSTEM. D4 - MODEL NO CHANGED FROM 14810 TO 19191. D4 - LOT NO CHANGED FROM BLANK TO L45654. D4 - CATALOG NO CHANGED FROM ZXY425 TO ZXP425. D4 - EXPIRATION DATE CHANGED FROM BLANK TO 9/22/2021. D4 - UNIQUE IDENTIFIER (UDI) # CHANGED FROM (B)(4). G5 - PMA/510(K) # CHANGED FROM K192659 TO K162296. H4 - DEVICE MFG DATE CHANGED FROM BLANK TO (B)(6) 2020.

    Additional Manufacturer Narrative · 1

    THE DEVICE HAS NOT BEEN RETURNED/RECEIVED TO DATE. IF THE DEVICE IS RECEIVED, A SUPPLEMENTAL REPORT WILL BE SUBMITTED WITH THE INVESTIGATION RESULTS. WE ARE UNABLE TO CONFIRM THE REPORTED NEEDLE MECHANISM FAILURE OR TO DETERMINE ITS ROOT CAUSE. NO LOT RELEASE RECORDS WERE REVIEWED, AS THE PRODUCT LOT NUMBER WAS NOT PROVIDED.

    Description of Event or Problem · 1

    IT WAS REPORTED THE NEEDLE DID NOT RETRACT, INDICATING A NEEDLE MECHANISM FAILURE. THE PATIENT'S BLOOD GLUCOSE LEVELS WERE UNAFFECTED, AND THE POD WAS WORN FOR LESS THAN AN HOUR.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    904831 OMNIPOD INSULIN MANAGEMENT SYSTEM PUMP, INFUSION, INSULIN LZG INSULET CORPORATION 19191 L45654

    Patients

    Seq Age Sex Outcome Treatment
    1