BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    OMNIPOD INSULIN PUMP

    MDR report key: 3940776 · Received April 22, 2014

    Report

    Report Number
    3004464228-2014-00522
    Event Type
    Malfunction
    Date Received
    April 22, 2014
    Date of Event
    March 25, 2014
    Report Date
    March 25, 2014
    Manufacturer
    INSULET CORPORATION
    Product Code
    LZG
    PMA / PMN Number
    K122953
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Occupation
    OTHER

    Narratives

    Additional Manufacturer Narrative · 1

    THE DEVICE WAS NOT RETURNED FOR EVALUATION. WE ARE UNABLE TO CONFIRM THE BENT CANNULA OR TO DETERMINE IF IT COULD HAVE CONTRIBUTED TO THE REPORTED HYPERGLYCEMIA. LOT QUALIFICATION RECORDS WERE REVIEWED AND THE PRODUCT LOT MET ALL ACCEPTANCE CRITERIA.

    Description of Event or Problem · 1

    TIME: 6:03 AM - POD ACTIVATED, BLOOD GLUCOSE (MG/DL): BOLUS (UNITS): 10:59AM, 252, 2.40U; 12:09PM, 265 - ATE 30G CARBS, 3.30U; 2:20PM, 322 - ATE 24G CARBS, 4.50U; 3:16PM, 321, 0.60U; 3:16PM - POD DEACTIVATED. WHEN THE POD WAS REMOVED, IT WAS NOTICED THAT THE CANNULA WAS BENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    242554 OMNIPOD INSULIN PUMP PUMP, INFUSION, INSULING LZG INSULET CORPORATION 14000 L40569

    Patients

    Seq Age Sex Outcome Treatment
    1 65 YR