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U.S. Department of Health and Human Services

MAUDE Adverse Event Report: INSULET CORPORATION OMNIPOD DASH INSULIN MANAGEMENT SYSTEM; PUMP, INFUSION, INSULIN

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INSULET CORPORATION OMNIPOD DASH INSULIN MANAGEMENT SYSTEM; PUMP, INFUSION, INSULIN Back to Search Results
Model Number 18320
Device Problem Material Twisted/Bent (2981)
Patient Problems Purulent Discharge (1812); Hyperglycemia (1905); Pain (1994); Burning Sensation (2146); Swelling/ Edema (4577)
Event Date 03/06/2023
Event Type  malfunction  
Manufacturer Narrative
The device has not been returned/received to date.If the device is received, a supplemental report will be submitted with the investigation results.We are unable to confirm the bent cannula or to determine if it could have contributed to the reported hyperglycemia and skin irritations.Lot release records were reviewed and the product lot met all acceptance criteria.Specifically, a pod is paired to a pdm and put through simulated use testing including confirming the blue soft cannula is inspected for any damage.
 
Event Description
It was reported that the patient's blood glucose levels reached 400 mg/dl.The pod was worn between 1 and 4 hours on the abdomen.Symptoms included swelling, pain, burning sensation and discharge.It was noted that the cannula was bent.Hyperglycemia treated with correctional bolus.
 
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Brand Name
OMNIPOD DASH INSULIN MANAGEMENT SYSTEM
Type of Device
PUMP, INFUSION, INSULIN
Manufacturer (Section D)
INSULET CORPORATION
100 nagog park
acton MA 01720
Manufacturer (Section G)
INSULET CORPORATION
100 nagog park
acton MA 01720
Manufacturer Contact
michael spears
100 nagog park
acton, MA 01720
9786007000
MDR Report Key16501344
MDR Text Key310861001
Report Number3004464228-2023-06405
Device Sequence Number1
Product Code LZG
UDI-Device Identifier20385082000020
UDI-Public(01)20385082000020(11)220513(17)231113(10)PD1K05132211
Combination Product (y/n)N
Reporter Country CodeUS
PMA/PMN Number
K211575
Number of Events Reported1
Summary Report (Y/N)N
Report Source Manufacturer
Source Type Foreign,Consumer
Reporter Occupation Other
Type of Report Initial
Report Date 03/07/2023
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 Date11/13/2023
Device Model Number18320
Device Catalogue NumberBLE-I1-529
Device Lot NumberPD1K05132211
Was Device Available for Evaluation? No
Initial Date Manufacturer Received 03/07/2023
Initial Date FDA Received03/08/2023
Was Device Evaluated by Manufacturer? Device Not Returned to Manufacturer
Date Device Manufactured05/13/2022
Is the Device Single Use? Yes
Type of Device Usage Initial
Patient Sequence Number1
Patient Age52 YR
Patient SexMale
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