FDA Adverse Event
Malfunction
Summary report: N
RESERVOIR 3ML
MDR report key: 2914586
·
Received January 14, 2013
Report
- Report Number
- 3004209178-2013-90279
- Event Type
- Malfunction
- Date Received
- January 14, 2013
- Date of Event
- December 31, 2012
- Report Date
- December 31, 2012
- Manufacturer
- MEDTRONIC PUERTO RICO OPERATIONS CO.
- Product Code
- FRN
- PMA / PMN Number
- K032005
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- ME
- 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. THE DEVICE WILL BE RETURNED FOR ANALYSIS AND FURTHER INFORMATION WILL FOLLOW ONCE THE ANALYSIS HAS BEEN COMPLETED.
Additional Manufacturer Narrative · 1
INSPECTED THREE RANDOMLY SEALED RESERVOIRS. PERFORMED PRE-FILL RESERVOIRS TEST. RESERVOIRS PASSED PER INSPECTION. FOUND NO LEAKAGE ANOMALY DURING FILLING. RESERVOIRS CONNECTED AND LOCKED IN PLACE PROPERLY.
Description of Event or Problem · 1
IT WAS REPORTED THAT INSULIN FROM THE RESERVOIR LEAKED. NO FURTHER INFORMATION WAS PROVIDED.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 21614 | RESERVOIR 3ML | RESERVOIR | FRN | MEDTRONIC PUERTO RICO OPERATIONS CO. | MMT-332A | H7878385 |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | 20 YR |