BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    POLYFIN QR W/WINGS

    MDR report key: 5663521 · Received May 18, 2016

    Report

    Report Number
    2032227-2016-11156
    Event Type
    Malfunction
    Date Received
    May 18, 2016
    Date of Event
    July 9, 2013
    Report Date
    July 9, 2013
    Manufacturer
    MEDTRONIC MINIMED
    Product Code
    FPA
    PMA / PMN Number
    K964456
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CH
    Reporter Occupation
    OTHER

    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

    THE CUSTOMER REPORTED VIA PHONE CALL THAT THEY RECEIVED A NO DELIVERY ALARM DURING PRIMING. THE CUSTOMER'S BLOOD GLUCOSE WAS UNKNOWN AT THE TIME OF INCIDENT. THE CUSTOMER PERFORMED PLUNGER PUSH AND THE INSULIN DID NOT EXIT THROUGH THE TUBING. THE INFUSION SET WILL NOT BE RETURNED FOR ANALYSIS.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    318901 POLYFIN QR W/WINGS FPA FPA MEDTRONIC MINIMED MMT-366 50656963

    Patients

    Seq Age Sex Outcome Treatment
    1