BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    RESERVOIR 1.8 ML

    MDR report key: 2800674 · Received October 22, 2012

    Report

    Report Number
    3004209178-2012-90252
    Event Type
    Malfunction
    Date Received
    October 22, 2012
    Date of Event
    October 5, 2012
    Report Date
    October 17, 2012
    Manufacturer
    MEDTRONIC PUERTO RICO OPERATIONS CO.
    Product Code
    FRN
    PMA / PMN Number
    K001828
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CA
    Reporter Occupation
    PATIENT

    Narratives

    Additional Manufacturer Narrative · 1

    CURRENTLY IT IS UNKNOWN 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

    THE CUSTOMER REPORTED THAT THE INSULIN FROM THE RESERVOIR WAS LEAKING INTO THE RESERVOIR COMPARTMENT. THE BLOOD GLUCOSE READING WAS 210MG/DL. NO FURTHER INFORMATION WAS PROVIDED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 RESERVOIR 1.8 ML FRN FRN MEDTRONIC PUERTO RICO OPERATIONS CO. MMT-326A H8081483

    Patients

    Seq Age Sex Outcome Treatment
    1 28 YR