BEUDAMED
    FDA Adverse Event Injury Summary report: N

    PARADIGM REAL-TIME INSULIN INFUSION PUMP

    MDR report key: 2033801 · Received March 17, 2011

    Report

    Report Number
    3004209178-2011-80707
    Event Type
    Injury
    Date Received
    March 17, 2011
    Date of Event
    March 1, 2011
    Report Date
    March 5, 2011
    Manufacturer
    MEDTRONIC PUERTO RICO OPERATIONS MED REL
    Product Code
    MDS
    PMA / PMN Number
    P980022
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    NY, US
    Reporter Occupation
    NOT APPLICABLE

    Narratives

    Additional Manufacturer Narrative · 1

    CURRENTLY, IT IS UNK WHETHER OR NOT THE DEVICE MAY HAVE CAUSED OR CONTRIBUTED TO THE EVENT AS NO PRODUCT HAS BEEN RETURNED. NO CONCLUSION CAN BE DRAWN AT THIS TIME. WE, THEREFORE, CONSIDER THIS REPORT COMPLETE TO THE BEST OF OUR KNOWLEDGE.

    Description of Event or Problem · 1

    IT WAS REPORTED THAT THE CUSTOMER WAS HOSPITALIZED DUE TO DIABETIC KETOACIDOSIS. THE CUSTOMER'S MOTHER STATED THAT THE CUSTOMER THOUGHT SHE HAD A STOMACH VIRUS AND INSTEAD FOUND THAT HER INFUSION SET HAD BROKEN OFF FROM THE RESERVOIR. THE CUSTOMER'S MOTHER ALSO STATED THAT FOR FIVE DAYS PRIOR TO THE EVENT, THE CUSTOMER HAD BEEN EXPERIENCING HIGH BLOOD GLUCOSE LEVELS. THE CUSTOMER'S MOTHER FURTHER STATED THAT THE CUSTOMER USED AN MMT-399 QUICK-SET INFUSION SET. PROGRAMMING WAS CORRECT AND TROUBLESHOOTING WAS PERFORMED, DURING WHICH THE INSULIN PUMP PASSED THE FIXED PRIME. NOTHING FURTHER WAS REPORTED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 PARADIGM REAL-TIME INSULIN INFUSION PUMP INSULIN INFUSION PUMP MDS MEDTRONIC PUERTO RICO OPERATIONS MED REL MMT-722NAB

    Patients

    Seq Age Sex Outcome Treatment
    1 19 YR Hospitalization