MAUDE Adverse Event Report: MEDTRONIC MINIMED INFST MMT-921T MIO 2PK 6MM 18IN PINK; SET, ADMINISTRATION, INTRAVASCULAR

Model Number MMT-921T

Device Problem Occlusion Within Device (1423)

Patient Problem Hyperglycemia (1905)

Event Date 02/17/2018

Event Type  Injury  

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.No conclusion can be drawn at this time.We therefore consider this report complete to the best of our knowledge.

Event Description

Customer reported via phone call that they received an insulin flow blocked alarm that was resolved by changing their infusion set.The customer's blood glucose level at the time of the incident was 480 mg/dl.Customer was not able to troubleshoot at the time of the call.Customer reported they continued to experience an elevated blood glucose level after changing out the infusion set.The infusion set is not expected to be returned.

• Brand Name: INFST MMT-921T MIO 2PK 6MM 18IN PINK
• 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: 7298355
• MDR Text Key: 100998363
• Report Number: 2032227-2018-01653
• Device Sequence Number: 1
• Product Code: FPA
• 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: 02/26/2018

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 02/26/2018
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Lay User/Patient
• Device Model Number: MMT-921T
• Device Catalogue Number: MMT-921T
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Date Manufacturer Received: 02/17/2018
• 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: 39 YR
• Patient Weight: 59