BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    ACCU-CHEK ® AVIVA TEST STRIPS

    MDR report key: 1961163 · Received January 14, 2011

    Report

    Report Number
    1823260-2011-00247
    Event Type
    Malfunction
    Date Received
    January 14, 2011
    Date of Event
    January 5, 2011
    Report Date
    January 19, 2011
    Manufacturer
    ROCHE DIAGNOSTICS
    Product Code
    LFR
    PMA / PMN Number
    K043474
    Removal / Correction Number
    NA
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    AL, US
    Reporter Occupation
    PATIENT

    Narratives

    Description of Event or Problem · 1

    CUSTOMER REPORTEDLY RECEIVED THE FOLLOWING RESULTS ON THE AVIVA SYSTEM WITHIN 10 MINUTES: 290 MG/DL AND 54 MG/DL. CUSTOMER WAS FEELING LOW BLOOD SUGAR SYMPTOMS AND DRANK A (B)(6). NO ADVERSE EVENT REPORTED. 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 ROCHE DIAGNOSTICS NA 303159

    Patients

    Seq Age Sex Outcome Treatment
    1 072 YR METFORMIN| NOVOLIN