MAUDE Adverse Event Report: MEDTRONIC MINIMED INFST MMT-876T SURETPRDGM 2PK 8MM32N 21L; SET, ADMINISTRATION, INTRAVASCULAR

Model Number MMT-876T

Device Problems Failure to Deliver (2338); Device Displays Incorrect Message (2591)

Patient Problem Hyperglycemia (1905)

Event Date 11/18/2016

Event Type  Injury  

Manufacturer Narrative

Note: this is a remediation mdr.Medtronic diabetes implemented revised mdr reportability criteria effective on (b)(6) 2017.Subsequently, medtronic diabetes conducted a two year retrospective review of complaints.This event was retrospectively identified to be reportable based on the revised mdr reportability criteria.Currently it is unknown whether or not the device may have caused or contributed to the event as no product has been returned.The device will be returned for analysis and further information will follow once the analysis has been completed.No conclusion can be drawn at this time.

Event Description

Customer reported via phone that they received a no delivery alarm.Customer's blood glucose level at the time of the incident was 574 mg/dl.Customer was able to troubleshoot.Customer disconnected at the quick release and attempted to perform a fixed prime.Customer reported that insulin did exit the infusion set tubing and the pump did not continue to alarm no delivery.Customer did not troubleshoot for the high blood glucose.The product is expected to be returned.

• Brand Name: INFST MMT-876T SURETPRDGM 2PK 8MM32N 21L
• Type of Device: SET, ADMINISTRATION, INTRAVASCULAR
• Manufacturer (Section D): MEDTRONIC MINIMED; 18000 devonshire st.; northridge CA 91325 1219
• Manufacturer (Section G): MEDTRONIC MINIMED; 18000 devonshire st.; northridge CA 91325 1219
• Manufacturer Contact: gerwin de graaff ; 18000 devonshire st.; northridge, CA 91325-1219
• MDR Report Key: 7238896
• MDR Text Key: 98931690
• Report Number: 2032227-2018-01234
• Device Sequence Number: 1
• Product Code: FPA
• UDI-Device Identifier: 20613994761419
• UDI-Public: (01)20613994761419(017)20200901
• Combination Product (y/n): N
• Reporter Country Code: US
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: consumer
• Reporter Occupation: Patient
• Type of Report: Initial
• Report Date: 02/02/2018

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Lay User/Patient
• Device Expiration Date: 09/01/2020
• Device Model Number: MMT-876T
• Device Catalogue Number: MMT-876T
• Device Lot Number: 002979917T
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Initial Date Manufacturer Received: 11/18/2016
• Initial Date FDA Received: 02/02/2018
• Date Device Manufactured: 08/16/2016
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Unknown
• Patient Sequence Number: 1
• Patient Outcome(s): Other
• Patient Age: 29 YR
• Patient Weight: 50