BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    OMNIPOD INSULIN PUMP

    MDR report key: 1478726 · Received July 2, 2009

    Report

    Report Number
    3004464228-2009-00533
    Event Type
    Malfunction
    Date Received
    July 2, 2009
    Date of Event
    May 17, 2009
    Report Date
    June 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 EVALUATION 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.

    Description of Event or Problem · 1

    THE REPORT INDICATED THAT THE CUSTOMER EXPERIENCED HIGH BGS (251-394 MG/DL) WHILE WEARING A POD DESPITE HAVING ADMINISTERED MULTIPLE CORRECTION BOLUSES. BLOOD WAS SEEN IN THE CANNULA, THOUGH NO KINK WAS NOTED. THE POD WAS DEACTIVATED AND WILL BE RETURNED FOR EVALUATION.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 OMNIPOD INSULIN PUMP PUMP, INFUSION, INSULIN LZG INSULET CORPORATION 11200 L30074

    Patients

    Seq Age Sex Outcome Treatment
    1 68 YR Other