BEUDAMED
    FDA Adverse Event Injury Summary report: N

    BELT CLIP PUMP CLEAR

    MDR report key: 4141798 · Received October 4, 2014

    Report

    Report Number
    2032227-2014-33563
    Event Type
    Injury
    Date Received
    October 4, 2014
    Date of Event
    September 4, 2014
    Report Date
    September 4, 2014
    Manufacturer
    MEDTRONIC MINIMED
    Product Code
    OYC
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    NC
    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

    CUSTOMER REPORTED A BROKEN BELT CLIP. THE CUSTOMER'S BLOOD GLUCOSE WAS 49 MG/DL. THE CUSTOMER TREATED THEIR LOW BLOOD GLUCOSE WITH JUICE. NO ADDITIONAL INFORMATION PROVIDED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    621784 BELT CLIP PUMP CLEAR INSULIN INFUSION PUMP / SENSOR AUGMENTED OYC MEDTRONIC MINIMED MMT-631CL

    Patients

    Seq Age Sex Outcome Treatment
    1 14 YR