MAUDE Adverse Event Report: MEDTRONIC PUERTO RICO OPERATIONS CO. 630G INSULIN PUMP MMT-1715K 630G BLACK MG; ARTIFICIAL PANCREAS DEVICE SYSTEM, THRESHOLD SUSPEND

Model Number MMT-1715K

Device Problem Adverse Event Without Identified Device or Use Problem (2993)

Patient Problems Abdominal Pain (1685); Dyspnea (1816); Headache (1880); Hyperglycemia (1905); Nausea (1970); Rash (2033); Vomiting (2144)

Event Date 06/12/2020

Event Type  Injury  

Manufacturer Narrative

(b)(4).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

The customer reported via phone call that they had hyperglycemia and was in emergency room on (b)(6) 2020.Blood glucose level of customer was 400 mg/dl.Customer was using insulin pump to treat the hyperglycemia.Customer was experiencing nausea, abdominal pain, breathing difficulty, vomiting, severe rash, headache and sever exhaustion.Customer was not using auto mode feature at the time of reported high blood glucose.At hospital customer was treated with other hydration fluids and drip.Customer was using insulin pump system within 48 hours of reported high blood glucose.Infusion set cannula was kink.Insulin pump will not be returned for analysis.

• Brand Name: 630G INSULIN PUMP MMT-1715K 630G BLACK MG
• Type of Device: ARTIFICIAL PANCREAS DEVICE SYSTEM, THRESHOLD SUSPEND
• Manufacturer (Section D): MEDTRONIC PUERTO RICO OPERATIONS CO.; ceiba norte ind. park #50 road; juncos 00777 -386; * 00777-3869
• Manufacturer (Section G): MEDTRONIC PUERTO RICO OPERATIONS CO.; ceiba norte ind. park #50 road; juncos 00777 -386; * 00777-3869
• Manufacturer Contact: gerwin de graaff ; ceiba norte ind. park #50 road; juncos 00777--386 ; * 00777-3869 ; 8185464805
• MDR Report Key: 10166648
• MDR Text Key: 195525498
• Report Number: 2032227-2020-132923
• Device Sequence Number: 1
• Product Code: OZO
• UDI-Device Identifier: 00763000316631
• UDI-Public: (01)00763000316631
• 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: Other
• Type of Report: Initial
• Report Date: 06/18/2020

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 06/18/2020
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Lay User/Patient
• Device Model Number: MMT-1715K
• Device Catalogue Number: MMT-1715K
• Device Lot Number: HG3ZSN9
• Was Device Available for Evaluation?: No
• Date Manufacturer Received: 06/13/2020
• Date Device Manufactured: 12/17/2019
• 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
• Treatment: UNOMED INF SET, FRN-MMT-332-RSVR
• Patient Outcome(s): Other
• Patient Age: 34 YR
• Patient Weight: 68