FDA Adverse Event Injury Summary report: N

ANIMAS ONE TOUCH PING INSULIN PUMP

MDR report key: 6559847 · Received May 9, 2017

Report

Report Number
MW5069682
Event Type
Injury
Date Received
May 9, 2017
Date of Event
May 6, 2017
Report Date
May 9, 2017
Manufacturer
ANIMAS / JOHNSON & JOHNSON
Product Code
LZG
Adverse Event
Yes
Report Source
Voluntary report
Reporter Location
SC, US
Reporter Occupation
PATIENT

Narratives

Description of Event or Problem · 1

I AM A 17-YEAR USER OF INSULIN PUMPS FOR TYPE 1 DIABETES SWITCHED FROM MEDTRONIC PUMPS TO AN ANIMAS PING PUMP IN (B)(6) 2017. THE PUMP MANUFACTURE DATE IS 08/2016 (S/N (B)(4)). IN (B)(6) 2017 I HAD THREE SEPARATE EPISODES OF DKA AND EXTREME HYPERGLYCEMIA DESPITE MULTIPLE CORRECTION BOLUSES AND INFUSION SET CHANGES; 2 CALLS TO ANIMAS TECHNICAL SUPPORT DID NOT IDENTIFY A PROBLEM. CORRECTION DOSES GIVEN BY TRADITIONAL INJECTION WERE REQUIRED WITH ALL THREE OCCASIONS, AND THE PROBLEM RESOLVED WITH ADD'L SITE CHANGES. ON THE LAST OCCASION, I NOTED INSULIN LEAKING OUT OF THE PUMP BETWEEN THE LUER CONNECTION AND THE RESERVOIR (ANIMAS 2.0 ML, CARTRIDGE, LOT D200363, USE BY 08/01/2018. UNOMEDICAL INSET30 REF 100-396-56, LOT 5153801, USE BY 07/01/2019. THIS WAS DIFFICULT TO DETECT BECAUSE THIS CONNECTION IS HIDDEN FROM VIEW AND COULDN'T BE REPLICATED WITH DISCONNECTING THE DEVICE AND PERFORMING A TEST BOLUS UNLESS YOU ALSO CRIMP/OCCLUDE THE DOWNSTREAM INFUSION SET TUBING. DISCONNECTING THE LUER CONNECTION REVEALED A NEARLY INVISIBLE CRACK IN THE LUER HUB ON THE TUBING END OF THE CONNECTION WHICH IS NOT VISIBLE WHEN THE DEVICE IS ASSEMBLED. I NOTIFIED THE MFR OF THE PUMP, BUT THEY CONSIDER THIS A FAILURE OF THE INFUSION SET WHICH THEY DO NOT MANUFACTURE. I SUSPECT THAT THE FAILURE RESULTS FROM THE ABILITY TO OVER-TORQUE THE CONNECTION BETWEEN THE RESERVOIR AND THE INFUSION TUBING HUB, BUT SINCE THE FAILURE IS IMPOSSIBLE TO DIAGNOSE UNTIL THE PUMP IS ACTUALLY FAILING TO DELIVER LARGE BOLUSES OF INSULIN (SMALL LEAKS ARE IMPOSSIBLE TO SEE BECAUSE OF THE PUMP DESIGN), I HAVE STOPPED PUMP THERAPY FOR THE FIRST TIME IN 17 YEARS WHILE I CONSIDER MY OPTIONS FOR AN ALTERNATE DEVICE DESIGN.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
336267 ANIMAS ONE TOUCH PING INSULIN PUMP ANIMAS ONE TOUCH PING INSULIN PUMP LZG ANIMAS / JOHNSON & JOHNSON 400-508-01RA
336268 INSET 30 SET, ADMINSISTRATION, INTRAVASCULAR FPA UNOMEDICAL 5153801

Patients

Seq Age Sex Outcome Treatment
1 42 YR Other 100-120 UNITS/DAY| ATORVASTATIN 10MG DAILY| HUMALOG PER PUMP, TOTAL DAILY DOSE -