BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    G4 PLATINUM PEDIATRIC CONTINUOUS GLUCOSE MONITORING SYSTEM

    MDR report key: 4150187 · Received October 7, 2014

    Report

    Report Number
    3004753838-2014-25597
    Event Type
    Malfunction
    Date Received
    October 7, 2014
    Date of Event
    September 10, 2014
    Report Date
    September 10, 2014
    Manufacturer
    DEXCOM, INC.
    Product Code
    MDS
    PMA / PMN Number
    P120005
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Occupation
    PATIENT FAMILY MEMBER OR FRIEND

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4). THE COMPLAINT DEVICE WAS RETURNED FOR EVALUATION. THE DEVICE WAS VISUALLY INSPECTED AND NO DEFECT WAS FOUND. FUNCTIONAL TESTING WAS PERFORMED AND THE REPORTED FAULT COULD NOT BE REPRODUCED AND THERE WAS NO FAILURE DETECTED. THE DEVICE WAS DETERMINED TO BE OPERATING WITHIN THE REQUIRED SPECIFICATIONS WITHOUT MALFUNCTION. AN ALARM TEST AND AN INTERIOR INSPECTION WAS PERFORMED AND THE DEVICE FAILED, CONFIRMING THE REPORTED EVENT OF LOW AUDIO OUTPUT. THE ROOT CAUSE WAS DETERMINED TO BE AN ASSEMBLY ERROR.

    Additional Manufacturer Narrative · 1

    (B)(4).

    Description of Event or Problem · 1

    PATIENT'S FATHER CONTACTED DEXCOM TECHNICAL SUPPORT ON (B)(6)2014 TO CLAIM LOW AUDIO OUTPUT ON (B)(6)2014. AT THE TIME CONTACT WITH DEXCOM TECHNICAL SUPPORT, NO MEDICAL INTERVENTION OR INJURIES WERE REPORTED. ADDITIONALLY, AT THE TIME OF CONTACT, DEXCOM TECHNICAL SUPPORT ADVISED PATIENT'S FATHER TO TEST THE ALERT FUNCTIONALITY AND PATIENT'S FATHER REPORTED ALERTS WERE FUNCTIONAL.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    627846 G4 PLATINUM PEDIATRIC CONTINUOUS GLUCOSE MONITORING SYSTEM MDS MDS DEXCOM, INC. MT22430-BLU

    Patients

    Seq Age Sex Outcome Treatment
    1 7 YR