BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    ACCU-CHEK AVIVA TEST STRIPS

    MDR report key: 1760970 · Received July 17, 2007

    Report

    Report Number
    1823260-2007-06169
    Event Type
    Malfunction
    Date Received
    July 17, 2007
    Date of Event
    July 7, 2007
    Report Date
    July 17, 2007
    Manufacturer
    ROCHE DIAGNOSTICS
    Product Code
    LFR
    PMA / PMN Number
    K043474
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    OH, US
    Reporter Occupation
    LAY USER/PATIENT

    Narratives

    Description of Event or Problem · 1

    CUSTOMER REPORTS THE FOLLOWING BACK TO BACK BLOOD GLUCOSE VALUES ON HER AVIVA SYSTEM: 97 MG/DL, 267 MG/DL, AND 111 MG/DL. NO TREATMENT WAS TAKEN BASED ON THE BACK TO BACK TESTS. NO ADVERSE EVENTS. REQUESTED RETURN OF SUSPECT DEVICE AND REPLACEMENT WAS SENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 ACCU-CHEK AVIVA TEST STRIPS BLOOD GLUCOSE MONITORING TEST STRIPS - LFR LFR ROCHE DIAGNOSTICS 300653

    Patients

    Seq Age Sex Outcome Treatment
    1 29 YR HUMULIN N 10 UNITS TWICE/DAY - 1 WEEK