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U.S. Department of Health and Human Services

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

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INSULET CORPORATION OMNIPOD INSULIN MANAGEMENT SYSTEM; PUMP, INFUSION, INSULIN Back to Search Results
Model Number 19191
Device Problem Premature Activation (1484)
Patient Problem No Clinical Signs, Symptoms or Conditions (4582)
Event Date 03/14/2023
Event Type  malfunction  
Event Description
It was reported that the needle and cannula deployed early, indicating a failure of the needle mechanism.The pod was not worn, and the blood glucose (bg) levels were unaffected.
 
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 reported needle mechanism failure or to determine its root cause.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 that the device deployed the cannula correctly.
 
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Brand Name
OMNIPOD 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
thom mcnamara
100 nagog park
acton, MA 01720
9786007000
MDR Report Key16832098
MDR Text Key314178546
Report Number3004464228-2023-10971
Device Sequence Number1
Product Code LZG
UDI-Device Identifier20385081120033
UDI-Public(01)20385081120033(11)220308(17)230908(10)L50373
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 04/27/2023
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 Date09/08/2023
Device Model Number19191
Device Catalogue NumberZXP425
Device Lot NumberL50373
Was Device Available for Evaluation? No
Initial Date Manufacturer Received 04/27/2023
Initial Date FDA Received04/28/2023
Was Device Evaluated by Manufacturer? Device Not Returned to Manufacturer
Date Device Manufactured03/08/2022
Is the Device Single Use? Yes
Type of Device Usage Initial
Patient Sequence Number1
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