MAUDE Adverse Event Report: TRIVIDIA HEALTH INC PEN NEEDLES FG; HYPODERMIC SINGLE LUMEN NEEDLE

Model Number	PNDL, 3BV TVH TP 31G 5MMTC 100CT 30/CS GREEN
Medical Device Problem Code	No Flow (2991)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	08/22/2022
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Internal report reference number:(b)(4).Pen needles were not returned for evaluation - customer had returned incorrect product (true metrix test strips).Note: manufacturer contacted customer in several follow-up calls to ensure the initial concern is resolved - unable to establish contact with customer at this time.
Event or Problem Description
Consumer reported complaint for the trueplus pen needles.Customer stated that some of the 31g pen needles were not aspirating.The package had not been open or damaged when received by the customer.The customer is using compatible pen injectors with the pen needles.Customer advised that he only has one pen needle left.At the time of the call the customer felt well and did not report any symptoms.Customer did not claim to be injured while using the pen needles and no medical intervention related to the use of the product was reported.Customer stating that out of his box of pen needles, he had some that were not aspirating.Customer is feeling well at this time and is not having any diabetic symptoms.No adverse events reported with the use of the product.Customer is using compatible pen injectors with the pen needles.Customer advised that he only has one needle left.Advised customer that i would send out a prepaid envelope for him to send back the pen needle.Advised customer to contact his pharmacy for any replacements.Will follow up.
Additional Manufacturer Narrative
Sections with additional information as of 09-nov-2022: h6: updated fda¿s type, findings and conclusions codes.H10: pen needles were not returned for evaluation - customer had returned incorrect product (true metrix test strips).Complaint was forwarded to supplier quality and internal evaluation was performed by the manufacturer using pen needles from the same lot.No abnormalities observed with retention samples.Most likely underlying root cause: mlc-009: use error caused or contributed to event.

• Brand Name: PEN NEEDLES FG
• Common Device Name: HYPODERMIC SINGLE LUMEN NEEDLE
• Manufacturer (Section D): TRIVIDIA HEALTH INC; 2400 nw 55th court; fort lauderdale FL 33309
• Manufacturer Contact: karen devincent ; 2400 nw 55th court; fort lauderdale, FL 33309
• MDR Report Key: 15418559
• Report Number: 1000113657-2022-00497
• Device Sequence Number: 6554457
• Product Code: FMI
• UDI-Device Identifier: 00021292012786
• UDI-Public: (01)00021292012786
• Combination Product (Y/N): N
• Initial Reporter State: MD
• Initial Reporter Country: US
• PMA/510(K) Number: K180720
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Consumer
• Initial Reporter Occupation: Other
• Remedial Action: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 11/09/2022

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 Model Number: PNDL, 3BV TVH TP 31G 5MMTC 100CT 30/CS GREEN
• Device Catalogue Number: S5H01B31-100TC
• Device Lot Number: 1K632
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Distributor Facility Aware Date: 08/22/2022
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 08/22/2022
• Supplement Date Received by Manufacturer: 10/17/2022
• Initial Report FDA Received Date: 09/14/2022
• Supplement Report FDA Received Date: 11/09/2022
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Is the Device Labeled for Single Use? (Y/N): No
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Patient Sex: Unknown