BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    ACCU-CHEK SPIRIT

    MDR report key: 1964558 · Received December 22, 2010

    Report

    Report Number
    2183996-2010-02670
    Event Type
    Malfunction
    Date Received
    December 22, 2010
    Date of Event
    December 13, 2010
    Report Date
    December 16, 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 Location
    CA, US
    Reporter Occupation
    UNKNOWN

    Narratives

    Description of Event or Problem · 1

    ON (B)(6) 2010, PT'S WIFE REPORTED THE UP BUTTON ON THE INFUSION DEVICE IS NOT WORKING ALL OF THE TIME. WIFE STATED, SHE NOTICED THE ISSUE WHILE TRYING TO BOLUS THIS WEEK. WIFE REPORTED, SHE PRESSES THE BUTTONS AND IT WILL NOT ALWAYS RESPOND, BUT SOMETIMES IT DOES. WIFE STATED, THE BUTTON POPS BACK UP AFTER IT HAS BEEN PRESSED. NO PHYSIOLOGICAL EFFECTS WERE REPORTED. THE PT DID NOT REQUIRE ASSISTANCE FROM A HEALTH CARE PROFESSIONAL OR SECOND PARTY TO ADDRESS THE ISSUE. PRODUCT WAS REPLACED AND REQUESTED RETURN OF THE ALLEGED PRODUCT FOR EVAL.

    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 69 YR INSULIN| INSULIN INFUSION SET