BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    ACCU-CHEK ® AVIVA PLUS TEST STRIPS

    MDR report key: 2820980 · Received November 6, 2012

    Report

    Report Number
    1823260-2012-05627
    Event Type
    Malfunction
    Date Received
    November 6, 2012
    Date of Event
    October 1, 2012
    Report Date
    November 13, 2012
    Manufacturer
    ROCHE DIAGNOSTICS
    Product Code
    LFR
    PMA / PMN Number
    K101299
    Removal / Correction Number
    NA
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    MD, US
    Reporter Occupation
    PATIENT

    Narratives

    Additional Manufacturer Narrative · 1

    IT WAS UNKNOWN IF THE INITIAL REPORTER SENT REPORT TO THE FDA.

    Description of Event or Problem · 1

    CUSTOMER REPORTEDLY RECEIVED THE FOLLOWING RESULTS ON THE AVIVA SYSTEM WITHIN 10 MINUTES: 516 MG/DL, 50 MG/DL, AND 41 MG/DL. CUSTOMER DRANK JUICE AFTER OBTAINING THE READINGS. NO ADVERSE EVENT REPORTED. REQUESTED RETURN OF SUSPECT DEVICE AND STRIPS, AND REPLACEMENT WAS SENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 ACCU-CHEK ® AVIVA PLUS TEST STRIPS BLOOD GLUCOSE MONITORING TEST STRIPS LFR ROCHE DIAGNOSTICS NA 490780

    Patients

    Seq Age Sex Outcome Treatment
    1 070 YR HUMULIN N 2X DAILY| BABY ASPIRIN 1X DAILY| SINGULAIR 1X DAILY| CRESTOR| THEOPHYLLINE| ADVAIR INHALER 2X DAILY| AMLODIPINE 1X DAILY| VITAMIN C 1X DAILY| OXYGEN| HUMALOG| PROAIR INHALER| SPIRIVA INHALER 1X DAILY| FISH OIL 1X DAILY