BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    RESERVOIR 3ML

    MDR report key: 4243509 · Received November 11, 2014

    Report

    Report Number
    2032227-2014-50149
    Event Type
    Malfunction
    Date Received
    November 11, 2014
    Date of Event
    September 29, 2014
    Report Date
    October 13, 2014
    Manufacturer
    MEDTRONIC PUERTO RICO OPERATIONS CO.
    Product Code
    FRN
    PMA / PMN Number
    K032005
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    SC
    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. (B)(4).

    Description of Event or Problem · 1

    IT WAS REPORTED THAT SHE WAS HAVING ISSUES WITH TWO OF HER RESERVOIRS. SHE STATED THE PLUNGER CAME OUT AND COULD NOT BE SCREWED BACK IN. THE CUSTOMER STATED SHE THREW BOTH RESERVOIRS AWAY. HER BLOOD GLUCOSE WAS NOT KNOWN. NOTHING FURTHER WAS REPORTED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    726816 RESERVOIR 3ML RESERVOIR FRN MEDTRONIC PUERTO RICO OPERATIONS CO. MMT-332A HG04QU5

    Patients

    Seq Age Sex Outcome Treatment
    1 67 YR