BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    ACCU-CHEK LINKASSIST PLUS

    MDR report key: 2141051 · Received June 16, 2011

    Report

    Report Number
    2183996-2011-01610
    Event Type
    Malfunction
    Date Received
    June 16, 2011
    Date of Event
    January 17, 2011
    Report Date
    May 16, 2011
    Manufacturer
    ROCHE INSULIN DELIVERY SYS INC.
    Product Code
    FRN
    PMA / PMN Number
    NA
    Removal / Correction Number
    NA
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    SP
    Reporter Occupation
    UNKNOWN

    Narratives

    Additional Manufacturer Narrative · 1

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

    Description of Event or Problem · 1

    PT REPORTED THE INSERTION ASSIST DEVICE RELEASES THE INFUSION SET UNINTENTIONALLY. NO FURTHER INFO IS AVAILABLE. NO PHYSIOLOGICAL EFFECTS WERE REPORTED. THE PT DID NOT REQUIRE ASSISTANCE FROM A HEALTHCARE PROFESSIONAL OR SECOND PARTY TO ADDRESS THE ISSUE. REQUESTED RETURN OF THE ALLEGED INSERTION ASSIST DEVICE FOR EVAL.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 ACCU-CHEK LINKASSIST PLUS INFUSION SET INSERTION DEVICE FRN ROCHE INSULIN DELIVERY SYS INC. NA UNK

    Patients

    Seq Age Sex Outcome Treatment
    1 28 YR INSULIN INFUSION PUMP| INSULIN INFUSION SET| INSULIN