BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    G4 PLATINUM PLATINUM CONTINUOUS GLUCOSE MONITORING SYSTEM

    MDR report key: 4222220 · Received November 3, 2014

    Report

    Report Number
    3004753838-2014-27928
    Event Type
    Malfunction
    Date Received
    November 3, 2014
    Date of Event
    October 6, 2014
    Report Date
    October 7, 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 RETURNED COMPLAINT DEVICE WAS VISUALLY INSPECTED AND NO DEFECT WAS FOUND. A REVIEW OF THE RECEIVER DATA LOG CONFIRMED A HARDWARE AND FIRMWARE ERROR CODE. THE ROOT CAUSE WAS DETERMINED TO BE A HARDWARE COMPONENT FAILURE. A CAPA HAS BEEN INITIATED FOR THIS ISSUE.

    Description of Event or Problem · 1

    PATIENT'S MOTHER CONTACTED DEXCOM TECHNICAL SUPPORT ON (B)(6) 2014 AND CLAIMED THAT ON (B)(6) 2014 THE PATIENT EXPERIENCED A HARDWARE FAILURE. DEXCOM TECHNICAL SUPPORT ADVISED THE PATIENT'S MOTHER TO RESET THE DEVICE ON (B)(6) 2014. DEXCOM HAS ISSUED AN RGA FOR PATIENT'S MOTHER TO RETURN THE DEVICE TO BE INVESTIGATED. PATIENT'S MOTHER DID NOT REPORT ANY INJURY OR MEDICAL INTERVENTION AT THE TIME OF CONTACT WITH DEXCOM TECHNICAL SUPPORT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    702333 G4 PLATINUM PLATINUM CONTINUOUS GLUCOSE MONITORING SYSTEM MDS MDS DEXCOM, INC. MT22430

    Patients

    Seq Age Sex Outcome Treatment
    1 12 YR