BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    ACCU-CHEK ® AVIVA TEST STRIPS

    MDR report key: 1873012 · Received October 18, 2010

    Report

    Report Number
    1823260-2010-06177
    Event Type
    Malfunction
    Date Received
    October 18, 2010
    Date of Event
    October 7, 2010
    Report Date
    November 23, 2010
    Manufacturer
    ROCHE DIAGNOSTICS
    Product Code
    LFR
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Occupation
    MEDICAL EQUIPMENT COMPANY TECHNICIAN/REPRESENTATIVE

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4). THIS MEDWATCH REPORT IS FOR THE SUSPECT DEVICE USED IN SYSTEM 1 (LOT NUMBER 202445, EXPIRATION DATE 06/30/2011). (B)(4).

    Description of Event or Problem · 1

    CUSTOMER REPORTEDLY RECEIVED THE FOLLOWING AVIVA NANO SYSTEM 1/AVIVA NANO SYSTEM 2 RESULTS WITHIN 10 MINUTES: HI (GREATER THEN 600 MG/DL), HI, AND 129 MG/DL; HI, HI, AND 89 MG/DL THE COMPARISONS WERE PERFORMED ON DIFFERENT DATES. CUSTOMER ADMINISTERED INSULIN BASED ON LOWER VALUES. NO ADVERSE EVENT REPORTED. REQUESTED RETURN OF SUSPECT DEVICE AND REPLACEMENT WAS SENT.

    Description of Event or Problem · 1

    PROCEDURE TYPE: CHOLECYSTECTOMY. ACCORDING TO THE REPORTER: DURING THE EXTRACTION OF THE PORT, THE TIP OF THE KNIFE BROKE AND PART OF THE PLASTIC COVER FELL OFF INSIDE THE PT'S CAVITY. NO PT INJURY WAS REPORTED. NO ADDITIONAL INFO AVAILABLE AT THIS TIME.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 ACCU-CHEK ® AVIVA TEST STRIPS BLOOD GLUCOSE MONITORING TEST STRIPS LFR ROCHE DIAGNOSTICS 202445

    Patients

    Seq Age Sex Outcome Treatment
    1 010 YR UNSPECIFIED INSULIN