MAUDE Adverse Event Report: ROCHE DIABETES CARE, INC. ACCU-CHEK GUIDE TEST STRIPS; BLOOD GLUCOSE MONITORING TEST STRIPS

Model Number	07453701001
Medical Device Problem Code	Incorrect, Inadequate or Imprecise Result or Readings (1535)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	08/30/2021
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
This case, with patient identifier (b)(6), is related to case with patient identifier (b)(6).
Event or Problem Description
Customer allegedly received the following results, with two different meters, within 15 minutes: 112 mg/dl (system 1), 222 mg/dl (system 2), and 115 mg/dl (system 2).

• Brand Name: ACCU-CHEK GUIDE TEST STRIPS
• Common Device Name: BLOOD GLUCOSE MONITORING TEST STRIPS
• Manufacturer (Section D): ROCHE DIABETES CARE, INC.; 9115 hague road; indianapolis IN 46250 0457
• MDR Report Key: 12436423
• Report Number: 3011393376-2021-02754
• Device Sequence Number: 19680964
• Product Code: NBW
• UDI-Device Identifier: 00365702701977
• UDI-Public: 00365702701977
• Combination Product (Y/N): N
• Initial Reporter State: MD
• Initial Reporter Country: US
• PMA/510(K) Number: K160944
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: consumer
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 09/23/2021

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
• Operator of Device: Lay User/Patient
• Device Expiration Date: 10/20/2022
• Device Model Number: 07453701001
• Device Catalogue Number: 08053774001
• Device Lot Number: 102671
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 09/14/2021
• Initial Date Received by Manufacturer: 08/30/2021
• Supplement Date Received by Manufacturer: 09/23/2021
• Initial Report FDA Received Date: 09/07/2021
• Supplement Report FDA Received Date: 09/23/2021
• Patient Sequence Number: 1
• Patient Age: 67 YR
• Patient Weight: 74