Brand Name | 630G INSULIN PUMP MMT-1715KL 630G |
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 |
|
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
|
8185464805
|
|
MDR Report Key | 11076206 |
MDR Text Key | 224590190 |
Report Number | 2032227-2020-221562 |
Device Sequence Number | 1 |
Product Code |
OZO
|
UDI-Device Identifier | 000000763000367053 |
UDI-Public | (01)000000763000367053(17)231028 |
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,Followup |
Report Date |
01/28/2021 |
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 Expiration Date | 10/28/2023 |
Device Model Number | MMT-1715KL |
Device Catalogue Number | MMT-1715KL |
Device Lot Number | HG4TD5D |
Was Device Available for Evaluation? |
Device Returned to Manufacturer
|
Date Returned to Manufacturer | 01/13/2021 |
Is the Reporter a Health Professional? |
No
|
Initial Date Manufacturer Received |
12/22/2020 |
Initial Date FDA Received | 12/28/2020 |
Supplement Dates Manufacturer Received | 01/27/2021
|
Supplement Dates FDA Received | 01/29/2021
|
Was Device Evaluated by Manufacturer? |
Device Not Returned to Manufacturer
|
Date Device Manufactured | 10/28/2020 |
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 |
Patient Age | 56 YR |
Patient Weight | 83 |