MAUDE Adverse Event Report: MEDTRONIC PUERTO RICO OPERATIONS CO. 640G INSULIN PUMP MMT-1711H; PUMP, INFUSION, INSULIN, TO BE USED WITH INVASIVE GLUCOSE SENSOR

Model Number MMT-1711H

Device Problems Break (1069); Crack (1135); Device Dislodged or Dislocated (2923)

Patient Problem No Consequences Or Impact To Patient (2199)

Event Date 05/01/2017

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.

Event Description

It was reported via phone call that the insulin pump had physical damage.Customer's blood glucose was 280mg/dl at the time of the incident.The retainer ring that holds the reservoir came off.Customer also mentioned the home button and the reservoir lip are cracked.Customer was advised the insulin pump will be replaced.The customer will return the product for analysis.

• Brand Name: 640G INSULIN PUMP MMT-1711H
• 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: 6604765
• MDR Text Key: 76593968
• Report Number: 3004209178-2017-51442
• Device Sequence Number: 1
• Product Code: OYC
• UDI-Device Identifier: 00643169739451
• UDI-Public: (01)00643169739451
• Combination Product (y/n): N
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,foreig
• Type of Report: Initial
• Report Date: 06/01/2017

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-1711H
• Device Catalogue Number: MMT-1711H
• Device Lot Number: HG13WSF
• Was Device Available for Evaluation?: No
• Initial Date Manufacturer Received: 05/03/2017
• Initial Date FDA Received: 06/01/2017
• 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