BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    ACCU-CHEK SPIRIT

    MDR report key: 1981892 · Received January 14, 2011

    Report

    Report Number
    2183996-2010-02777
    Event Type
    Malfunction
    Date Received
    January 14, 2011
    Date of Event
    December 29, 2010
    Report Date
    December 31, 2010
    Manufacturer
    ROCHE INSULIN DELIVERY SYSTEMS INC.
    Product Code
    LZG
    PMA / PMN Number
    NA
    Removal / Correction Number
    NA
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    IT
    Reporter Occupation
    UNKNOWN

    Narratives

    Additional Manufacturer Narrative · 1

    THIS INCIDENT OCCURRED OUTSIDE THE UNITED STATES. INFORMATION CONTAINED WITHIN THIS REPORT IS ALL THAT IS AVAILABLE AT THIS TIME. IF FURTHER INFORMATION IS OBTAINED IT WILL BE PROVIDED IN THE SUPPLEMENTAL REPORT.

    Description of Event or Problem · 1

    THE PATIENT'S FATHER REPORTED THE PATIENT'S BLOOD GLUCOSE ELEVATED TO 290 MG/DL. HER NORMAL BLOOD GLUCOSE LEVEL IS 120 MG/DL. THE PATIENT DOES NOT BELIEVE THE INFUSION DEVICE IS DELIVERING THE BASAL RATES OR BOLUS CORRECTLY. THE PATIENT SWITCHED TO INSULIN INJECTION. NO FURTHER INFORMATION IS AVAILABLE. THE PATIENT DID NOT REQUIRE TREATMENT FROM A HEALTH CARE PROFESSIONAL OR SECOND PARTY TO ADDRESS THE ISSUE. THE INFUSION DEVICE WAS REQUESTED TO BE RETURNED FOR EVALUATION.

    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 22 YR INSULIN INFUSION SET| INSULIN