BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    ACCU-CHEK SPIRIT

    MDR report key: 1890710 · Received November 1, 2010

    Report

    Report Number
    2183996-2010-02199
    Event Type
    Malfunction
    Date Received
    November 1, 2010
    Date of Event
    October 15, 2010
    Report Date
    October 22, 2010
    Manufacturer
    ROCHE INSULIN DELIVERY SYSTEMS INC.
    Product Code
    LZG
    PMA / PMN Number
    K060876
    Removal / Correction Number
    Z-1415-2009
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Occupation
    UNKNOWN

    Narratives

    Description of Event or Problem · 1

    ON (B)(6) 2010, PT REPORTED UP BUTTON ON INFUSION DEVICE WAS NOT FUNCTIONING PROPERLY. THIS WAS NOTICED ONE WEEK PRIOR TO REPORT AND HAS BECOME WORSE. UP BUTTON POPS UP AFTER IT IS PRESSED. INFUSION DEVICE WAS NOT DROPPED OR EXPOSED TO WATER OR INSULIN INGRESS. PT HAS USED THIS INFUSION DEVICE FOR 2 YRS AND BOLUSES APPROX 6 TIMES PER DAY. INFUSION DEVICE WAS REPLACED AND REQUESTED FOR EVAL. NO PHYSIOLOGICAL EFFECTS WERE REPORTED. THE PT DID NOT REQUIRE TREATMENT FROM A HEALTHCARE PROFESSIONAL OR SECOND PARTY TO ADDRESS THE ISSUE.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 ACCU-CHEK SPIRIT INSULIN INFUSION PUMP LZG ROCHE INSULIN DELIVERY SYSTEMS INC. NA NA

    Patients

    Seq Age Sex Outcome Treatment
    1 29 YR INSULIN INFUSION SET| INSULIN