BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    RESERVOIR 3ML

    MDR report key: 3854515 · Received June 6, 2014

    Report

    Report Number
    3004209178-2014-85347
    Event Type
    Malfunction
    Date Received
    June 6, 2014
    Date of Event
    April 30, 2014
    Report Date
    May 22, 2014
    Manufacturer
    MEDTRONIC PUERTO RICO OPERATIONS CO.
    Product Code
    FRN
    PMA / PMN Number
    K032005
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    MO
    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 HAVING A HIGH BLOOD GLUCOSE OF 336 MG/DL. TROUBLESHOOTING WAS PERFORMED WITH THE RESERVOIR AND THE CUSTOMER STATED HE DID NOT FIND A LEAK, BUT THAT THE INSIDE WAS SLIGHTLY DAMP. THE CUSTOMER WAS ADVISED TO CHANGE THE ENTIRE INFUSION SET, RESERVOIR, AND INSULIN. NOTHING FURTHER WAS REPORTED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    332272 RESERVOIR 3ML RESERVOIR FRN MEDTRONIC PUERTO RICO OPERATIONS CO. MMT-332A

    Patients

    Seq Age Sex Outcome Treatment
    1 47 YR