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U.S. Department of Health and Human Services


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Model Number MS9557
Device Problems Break (1069); Improper or Incorrect Procedure or Method (2017); Mechanical Jam (2983)
Patient Problem Hypoglycemia (1912)
Event Type  Injury  
Manufacturer Narrative
If device is returned, evaluation will be performed to determine if a malfunction has occurred. This is an initial report. A follow-up report will be submitted when the final evaluation is completed. This report is associated with 1819470-2021-00165 since there is more than one device implicated.
Event Description
(b)(4). This report is associated with product complaint: (b)(4). This solicited case, reported by a consumer via a patient support program (psp), concerned a (b)(6) pediatric male patient of an unknown origin. Medical history was unknown. Concomitant medication included insulin glargine for diabetes. The patient received insulin lispro (rdna origin) (humalog), via a device humapen ergo ii and humapen luxura half dose (hd), subcutaneously for the treatment of diabetes mellitus beginning on unknown date in 2015 (also reported as 2014). Since an unknown date, every time he had insulin lispro injection via humapen ergo ii (full doses) ever since humapen luxura hd was lost ((b)(4), lot number 1201g07), he experienced uncontrolled blood sugar and decrease blood glucose level which was 200 mg/dl and 40 mg/dl (reference range not provided). His mother stated that he needed dose correction using half units humapen ergo ii as he was young and whole units are too much for him. On an unknown date, he was administered 1 iu of insulin lispro as a corrective dose and he experienced sever hypoglycemia. It was reported that humapen ergo ii got impaired after 10 days as its screw got stuck (lot number unknown, (b)(4)). He suffered from low blood glucose levels (units, values and reference range was not provided) while taking insulin lispro using humapen ergo. On (b)(6) 2021, as the cartridge holder was broken and displaced from its place, and screw got attached strictly to the humapen. Then he started taking insulin lispro using syringes, but he was suffering from low blood glucose levels and bluish color at site of injection. It was reported that syringes were the worst way to take insulin as it was very painful, and dose cannot be adjusted other than 1 unit. It was also reported that she covered the additional dose with food or honey for him, as in case of taking 1 unit without covering the rest of dose with food he would suffer from low blood glucose levels and blood glucose level reaches 30 mg/dl. The event of second episode of blood glucose decreased was considered as serious by the company due to its medical significance. He had not recovered from the events of injection site bruising, blood glucose increased and first episode of blood glucose decreased and incorrect dose administered. Information regarding the corrective treatment for the events was not provided. Outcome of the remaining events were not provided. Insulin lispro therapy was continued. The operator of the humapen ergo ii and humapen luxura hd was the mother of patient and her training status was not provided. Device duration of use for humapen ergo ii and humapen luxura hd model duration of use was unknown since start date was not provided. Action taken with suspect humapen ergo ii and humapen luxura hd was not provided and their return was expected. The initial reporting consumer did not relate the events blood glucose increased and blood glucose decreased with insulin lispro whereas related the events with humapen ergo ii and humapen luxura hd devices. The reporting consumer related the event blood glucose decreased with the humapen devices. The reporting consumer did not provide a relatedness assessment between the remaining events and insulin lispro therapy or the humapen devices. Update 28-oct-2021: additional information received on 05-oct-2021 from the initial reporter via psp. Added: non-serious event hypoglycemia. Updated patient date of birth. Narrative updated accordingly. Update 11-nov-2021: additional information was received from the initial reporting consumer via the psp on 08-nov-2021. This case was upgraded to serious due to addition of serious event of blood glucose decreased. Added two new non serious events of injection site bruising and incorrect dose administered. Updated device elements, eu(b)(6) fields, device paragraph, causality assessment statement and narrative with new information. Update 08-dec-2021: additional information was received on 05-dec-2021 and 06dec2021 which were processed together. Pc numbers were updated in the narrative. Updated medwatch and european and (b)(6) (eu/(b)(6)) fields for expedited device reporting. No new information added.
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Manufacturer (Section D)
lilly corporate center
indianapolis IN 46285
Manufacturer (Section G)
lilly corporate center
indianapolis IN 46285
Manufacturer Contact
chris davis
lilly corporate center
indianapolis, IN 46285
MDR Report Key12964155
MDR Text Key286448890
Report Number1819470-2021-00164
Device Sequence Number1
Product Code FMF
Combination Product (y/n)N
Reporter Country CodeEG
PMA/PMN Number
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type Foreign,Study,Consumer,Company Representative
Reporter Occupation
Type of Report Initial,Followup
Report Date 01/14/2022
1 Device was Involved in the Event
1 Patient was Involved in the Event
Date FDA Received12/08/2021
Is this an Adverse Event Report? Yes
Is this a Product Problem Report? No
Device Operator
Device Model NumberMS9557
Was Device Available for Evaluation? Yes
Date Manufacturer Received12/20/2021
Was Device Evaluated by Manufacturer? Yes
Is the Device Single Use? No
Is This a Reprocessed and Reused Single-Use Device? No
Type of Device Usage Initial

Patient Treatment Data
Date Received: 12/08/2021 Patient Sequence Number: 1