MAUDE Adverse Event Report: MEDTRONIC PUERTO RICO OPERATIONS CO. PARADIGM REAL-TIME INSULIN INFUSION PUMP MMT-554WWS; PUMP, INFUSION, INSULIN, TO BE USED WITH INVASIVE GLUCOSE SENSOR

Model Number MMT-554WWS

Device Problems Break (1069); Fluid/Blood Leak (1250); Device Displays Incorrect Message (2591); Material Protrusion/Extrusion (2979)

Patient Problem No Consequences Or Impact To Patient (2199)

Event Date 05/21/2018

Event Type  malfunction  

Manufacturer Narrative

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.The insulin pump involved in this event is the 640g insulin infusion pump, which is not marketed in the united states.However, the device is similar to the paradigm real-time insulin infusion pump, which is marketed in the united states.

Event Description

It was reported that the customer's insulin pump had alarmed compromised force sensor system.The customer¿s blood glucose level was 11.3 mmol/l at the time of the incident.The customer reported that they had compromised force sensor system and insulin squirt out during manual prime.The customer stated that the drive support cap was sticking out.The customer was asked customer verbally and in written form to return broken pump for analysis.The insulin pump will be returned for analysis.

Manufacturer Narrative

Insulin pump passed displacement test.However, insulin pump alarmed compromised force sensor system alarm during basic occlusion test due to slightly loose drive support disk.

• Brand Name: PARADIGM REAL-TIME INSULIN INFUSION PUMP MMT-554WWS
• Type of Device: PUMP, INFUSION, INSULIN, TO BE USED WITH INVASIVE GLUCOSE SENSOR
• Manufacturer (Section D): MEDTRONIC PUERTO RICO OPERATIONS CO.; ceiba norte ind. park #50 road; juncos 00777 -386
• Manufacturer (Section G): MEDTRONIC PUERTO RICO OPERATIONS CO.; ceiba norte ind. park #50 road; juncos 00777 -386
• Manufacturer Contact: gerwin de graaff ; ceiba norte ind. park #50 road; juncos 00777--386
• MDR Report Key: 7600105
• MDR Text Key: 111479055
• Report Number: 3004209178-2018-81384
• Device Sequence Number: 1
• Product Code: OYC
• UDI-Device Identifier: 00643169304802
• UDI-Public: (01)00643169304802
• Combination Product (y/n): N
• Reporter Country Code: GM
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,foreig
• Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date: 12/04/2018

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Lay User/Patient
• Device Model Number: MMT-554WWS
• Device Catalogue Number: MMT-554WWS
• Device Lot Number: B3554WWSJ
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 09/12/2018
• Is the Reporter a Health Professional?: No
• Initial Date Manufacturer Received: 05/21/2018
• Initial Date FDA Received: 06/14/2018
• Supplement Dates Manufacturer Received: 11/30/2018
• Supplement Dates FDA Received: 12/04/2018
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Date Device Manufactured: 06/16/2014
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Unknown
• Patient Sequence Number: 1