BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    PARADIGM REAL-TIME REVEL INSULIN INFUSION PUMP

    MDR report key: 4221720 · Received November 3, 2014

    Report

    Report Number
    2032227-2014-46656
    Event Type
    Malfunction
    Date Received
    November 3, 2014
    Date of Event
    October 4, 2014
    Report Date
    October 4, 2014
    Manufacturer
    MEDTRONIC PUERTO RICO OPERATIONS CO.
    Product Code
    OYC
    PMA / PMN Number
    P980022
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    IN
    Reporter Occupation
    OTHER

    Narratives

    Additional Manufacturer Narrative · 1

    (B)(4). 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 THAT SHE RECEIVED A NO DELIVERY ALARM. CUSTOMER WAS ADVISED TO DISCONNECT AND RECONNECT THE TUBING AND RESERVOIR AND PERFORM MANUAL PRIME; INSULIN DID NOT EXIT THE TUBING. CUSTOMER CHANGED THE INFUSION SET AND CONNECTED WITH CURRENT RESERVOIR AND STATED THAT THE INSULIN DID NOT EXIT THE TUBING WITH PLUNGER PUSH. CUSTOMER THEN CHANGED THE RESERVOIR AND STATED THAT THE INSULIN PUMP DID NOT ALARM NO DELIVERY WITH MANUAL PRIME. CUSTOMER WAS ADVICES THAT CHANGING THE RESERVOIR RESOLVED THE ISSUE. BLOOD GLUCOSE VALUE IS 70 MG/DL. NOTHING FURTHER REPORTED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    702448 PARADIGM REAL-TIME REVEL INSULIN INFUSION PUMP INSULIN INFUSION PUMP / SENSOR AUGMENTED OYC MEDTRONIC PUERTO RICO OPERATIONS CO. MMT-723NAH

    Patients

    Seq Age Sex Outcome Treatment
    1 55 YR