BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    PUMP MMT-1712KL 640G V4.10 BK SF MG

    MDR report key: 12275246 · Received August 4, 2021

    Report

    Report Number
    2032227-2021-176547
    Event Type
    Malfunction
    Date Received
    August 4, 2021
    Date of Event
    July 23, 2021
    Report Date
    January 25, 2022
    Manufacturer
    MEDTRONIC PUERTO RICO OPERATIONS CO.
    Product Code
    OYC
    UDI-DI
    000000763000367046
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    BE
    Reporter Occupation
    OTHER
    Health Professional
    N

    Narratives

    Additional Manufacturer Narrative · 0

    RETAINER = BLACK. CUSTOMER RETURNED THE INSULIN PUMP FOR AN ALLEGED UNRESPONSIVE KEYPAD AND COSMETIC DAMAGE LOCATED ON THE KEYPAD OVERLAY (CRACK) FOUND ON 7/232021. THE INSULIN PUMP WAS RECEIVED WITH NO BUTTON RESPONSE. THE INSULIN PUMP WAS CUT OPEN TO PERFORM VISUAL INSPECTION AND CORROSION/MOISTURE DAMAGE WAS FOUND ON PCBA 1 AND THE KEYPAD FLEX TAIL NO MOISTURE DAMAGE WAS FOUND ON THE KEYPAD ASSEMBLY, PCBA 2, MOTOR, OR FORCE SENSOR. UNABLE TO PERFORM THE DISPLACEMENT TEST, SELF TEST, OR THE KEYPAD VOLTAGE TEST DUE TO NO BUTTON RESPONSE. NO BUTTON RESPONSE IS DUE TO CORROSION/MOISTURE DAMAGE ON PCB 1. A TEST P-CAP DOES LOCK INTO PLACE INSIDE THE RESERVOIR COMPARTMENT PROPERLY. THE FOLLOWING WERE NOTED DURING PHYSICAL INSPECTION: SCRATCHED CASE, PILLOWING KEYPAD OVERLAY, BATTERY COMPARTMENT CRACKED AT THE CORNER OF THE BELT CLIP RAILS, AND CRACKED BATTERY TUBE THREADS. NO CRACK ON THE KEYPAD OVERLAY NOTED DURING PHYSICAL INSPECTION. COSMETIC DAMAGE ON THE KEYPAD OVERLAY (CRACK) IS NOT CONFIRMED HOWEVER, OTHER COSMETIC DAMAGE WAS NOTED. NO BUTTON RESPONSE IS CONFIRMED. NO BUTTON RESPONSE IS DUE TO CORROSION/MOISTURE DAMAGE ON PCBA 1. MEDTRONIC, INC. (MEDTRONIC) IS SUBMITTING THIS REPORT TO COMPLY WITH 21 C.F.R. PART 803, THE MEDICAL DEVICE REPORTING REGULATION. THIS REPORT IS BASED UPON INFORMATION OBTAINED BY MEDTRONIC, WHICH THE COMPANY MAY NOT HAVE BEEN ABLE TO FULLY INVESTIGATE OR VERIFY PRIOR TO THE DATE THE REPORT WAS REQUIRED BY THE FDA. MEDTRONIC HAS MADE REASONABLE EFFORTS TO OBTAIN MORE COMPLETE INFORMATION IN THE TIME ALLOTTED AND HAS PROVIDED AS MUCH INFORMATION AS IS AVAILABLE TO THE COMPANY AS OF THE SUBMISSION DATE THIS REPORT. THIS REPORT DOES NOT CONSTITUTE AN ADMISSION OR A CONCLUSION BY FDA, MEDTRONIC, OR ITS EMPLOYEES THAT THE DEVICE, MEDTRONIC, OR ITS EMPLOYEES CAUSED OR CONTRIBUTED TO THE EVENT DESCRIBED IN THE REPORT. IN PARTICULAR, THIS REPORT DOES NOT CONSTITUTE AN ADMISSION BY ANYONE THAT THE PRODUCT DESCRIBED IN THIS REPORT HAS ANY "DEFECTS" OR HAS "MALFUNCTIONED". THESE WORDS ARE INCLUDED IN THE FDA 3500A FORM AND ARE FIXED ITEMS FOR SELECTION CREATED BY THE FDA, TO CATEGORIZE THE TYPE OF EVENT SOLELY FOR THE PURPOSE OF REPORTING PURSUANT TO PART 803. MEDTRONIC OBJECTS TO THE USE OF THESE WORDS AND OTHERS LIKE IT BECAUSE OF THE LACK OF DEFINITION AND THE CONNOTATIONS IMPLIED BY THESE TERMS. THIS STATEMENT SHOULD BE INCLUDED WITH ANY INFORMATION OR REPORT DISCLOSED TO THE PUBLIC UNDER THE FREEDOM OF INFORMATION ACT.

    Additional Manufacturer Narrative · 1

    (B)(4). CURRENTLY IT IS UNKNOWN WHETHER OR NOT THE DEVICE MAY HAVE CAUSED OR CONTRIBUTED TO THE EVENT AS NO PRODUCT HAS BEEN RETURNED. THE DEVICE WILL BE RETURNED FOR ANALYSIS AND FURTHER INFORMATION WILL FOLLOW ONCE THE ANALYSIS HAS BEEN COMPLETED. NO CONCLUSION CAN BE DRAWN AT THIS TIME. THE INSULIN PUMP INVOLVED IN THIS EVENT IS THE PARADIGM REAL-TIME VEO INSULIN INFUSION PUMP, WHICH IS NOT MARKETED IN THE UNITED STATES. HOWEVER, THE DEVICE IS SIMILAR TO THE PARADIGM REAL-TIME INSULIN INFUSION PUMP, WHICH IS MARKETED IN THE UNITED STATES.

    Description of Event or Problem · 1

    INFORMATION RECEIVED BY MEDTRONIC INDICATED THAT THE INSULIN PUMP KEYPAD WAS NOT RESPONDING. THE TROUBLESHOOTING WAS PERFORMED. NO HARM REQUIRING MEDICAL INTERVENTION WAS REPORTED. THE INSULIN PUMP WILL BE RETURNED FOR ANALYSIS.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1175697 PUMP MMT-1712KL 640G V4.10 BK SF MG PUMP, INFUSION, INSULIN, TO BE USED WITH INVASIVE GLUCOSE SENSOR OYC MEDTRONIC PUERTO RICO OPERATIONS CO. MMT-1712KL HG5BPNF 000000763000367046

    Patients

    Seq Age Sex Outcome Treatment
    1 Unknown