BEUDAMED
    FDA Adverse Event Injury Summary report: N

    530G INSULIN PUMP

    MDR report key: 4780798 · Received May 19, 2015

    Report

    Report Number
    3004209178-2015-57486
    Event Type
    Injury
    Date Received
    May 19, 2015
    Date of Event
    April 28, 2015
    Report Date
    April 28, 2015
    Manufacturer
    MEDTRONIC PUERTO RICO OPERATIONS CO.
    Product Code
    OZO
    PMA / PMN Number
    120010
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    NJ
    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

    IT WAS REPORTED VIA PHONE CALL, THAT THE CUSTOMER WAS HOSPITALIZED ON (B)(6) 2015 DUE TO DIABETIC KETOACIDOSIS. CUSTOMER'S BLOOD GLUCOSE LEVELS AT THE TIME OF HOSPITALIZATION 575 MG/DL. THE CUSTOMER REPORTED HAVING SYMPTOMS OF MUSCLE WEAKNESS, CHEST PAINS, NAUSEA, AND DIZZINESS. THE CUSTOMER WAS NOT WEARING THE INSULIN PUMP FOR TWO DAYS PRIOR TO THE TIME OF HOSPITALIZATION. TROUBLESHOOTING WAS DECLINED. NO SIGNIFICANT EVENT LEADING UP TO THE INCIDENT WAS MENTIONED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    325533 530G INSULIN PUMP OZO OZO MEDTRONIC PUERTO RICO OPERATIONS CO. MMT-751NAB

    Patients

    Seq Age Sex Outcome Treatment
    1 20 YR Hospitalization