BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    OMNIPOD INSULIN PUMP

    MDR report key: 1366042 · Received January 23, 2009

    Report

    Report Number
    3004464228-2009-00052
    Event Type
    Malfunction
    Date Received
    January 23, 2009
    Date of Event
    January 2, 2009
    Report Date
    January 2, 2009
    Manufacturer
    INSULET CORPORATION
    Product Code
    LZG
    PMA / PMN Number
    K042792
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Occupation
    NOT APPLICABLE

    Narratives

    Additional Manufacturer Narrative · 1

    THE RETURNED PRODUCT EVAL CONFIRMED AN INTERNAL LEAK WHICH CAUSED DAMAGE TO THE DEVICE AFTER BEING FILLED WITH INSULIN. THE USER IS INSTRUCTED IN THE USER GUIDE TO FREQUENTLY MONITOR THEIR BG LEVELS. BY FOLLOWING THIS RECOMMENDATION, THE USER WAS AWARE OF HIGH BG LEVELS AND WAS ABLE TO START A NEW POD SUCCESSFULLY. THE LOT WAS FOUND TO HAVE MET ALL ACCEPTANCE CRITERIA.

    Description of Event or Problem · 1

    CUSTOMER'S MOTHER CALLED TO REPORT A POD ALARMED WHILE HER SON WAS SLEEPING. SHE ALSO STATED THAT HER SON'S BLOOD GLUCOSE READINGS WERE ELEVATED AND RANGED BETWEEN 230-445 MG/DL. CUSTOMER WAS ABLE TO START A NEW POD SUCCESSFULLY. NO FURTHER ISSUES WERE IDENTIFIED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 OMNIPOD INSULIN PUMP PUMP, INFUSION, INSULIN LZG INSULET CORPORATION 11200 L11850

    Patients

    Seq Age Sex Outcome Treatment
    1 15 YR Other