MAUDE Adverse Event Report: CONTACT DETACH; SET, ADMINISTRATION, INTRAVASCULAR

Model Number	MMT-863
Medical Device Problem Code	Premature Separation (4045)
Health Effect - Clinical Code	Hyperglycemia (1905)
Date of Event	10/30/2024
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Based on the available information, this event is deemed to be a reportable malfunction.To date no additional information has been received.Should additional information become available, a follow-up report will be submitted.Fda registration number.Reporting site: 8021545.Manufacturing site: 3003442380.
Event or Problem Description
The patient reported the infusion set detached during sleep on (b)(6) 2024, resulting in blood glucose elevation to 270 mg/dl sustained for 5 hours, which further increased to 352 mg/dl following a meal despite changing the infusion site.

• Brand Name: CONTACT DETACH
• Common Device Name: SET, ADMINISTRATION, INTRAVASCULAR
• Manufacturer Contact: courtney smith ; aaholmvej 1 - 3; osted; lejre 4320 ; DA 4320 ; 6032470255
• MDR Report Key: 24826404
• Report Number: 3003442380-2026-86793
• Device Sequence Number: 18447147
• Product Code: FPA
• UDI-Device Identifier: 05705244005693
• UDI-Public: 05705244005693
• Combination Product (Y/N): N
• PMA/510(K) Number: K041545
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Consumer
• Initial Reporter Occupation: Non-Healthcare Professional
• Type of Report: Initial
• Report Date (Section B): 03/10/2026

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 Model Number: MMT-863
• Device Lot Number: 6007038
• Was Device Available for Evaluation?: No
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/10/2026
• Initial Report FDA Received Date: 04/09/2026
• Date Device Manufactured: 05/04/2024
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: A
• Patient Sequence Number: 1
• Patient Age: 83 YR
• Patient Sex: Unknown