BEUDAMED
    FDA Adverse Event Injury Summary report: N

    PUMP MMT-1780KPK 670G PATHWAY BLACK MG

    MDR report key: 8427641 · Received March 18, 2019

    Report

    Report Number
    3004209178-2019-68774
    Event Type
    Injury
    Date Received
    March 18, 2019
    Date of Event
    March 12, 2019
    Report Date
    March 18, 2019
    Manufacturer
    MEDTRONIC PUERTO RICO OPERATIONS CO.
    Product Code
    OZP
    UDI-DI
    00763000190460
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    TX, US
    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 EXPERIENCED LOW BLOOD GLUCOSE. THE CUSTOMER¿S BLOOD GLUCOSE WAS INTO 38, 233, 184, 34 MG/DL. THE INSULIN PUMP HAD INSULIN FLOW BLOCKED ALARM. THE CUSTOMER DECLINED HIGH BLOOD GLUCOSE TROUBLESHOOTING AND STATED THAT HE WAS NOT SURE IF HE WAS GETTING THE INSULIN SO HER DID A MANUAL. THE CUSTOMER STATED THAT HIS BLOOD GLUCOSE GOT TO 38 MG/DL DUE TO OVER BOLUS YESTERDAY. THE TROUBLESHOOTING WAS PERFORMED FOR INSULIN FLOW BLOCK ALARM. CUSTOMER STATED THAT THE INSULIN EXITED. THE PRODUCT WILL NOT BE RETURNED FOR ANALYSIS.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    222161 PUMP MMT-1780KPK 670G PATHWAY BLACK MG ARTIFICIAL PANCREAS DEVICE SYSTEM, SINGLE HORMONAL CONTROL OZP MEDTRONIC PUERTO RICO OPERATIONS CO. MMT-1780KPK HG2WVJA 00763000190460

    Patients

    Seq Age Sex Outcome Treatment
    1 63 YR Other UNOMEDICAL SET, FRN-UNKNOWN-RSVR