MAUDE Adverse Event Report: TRIVIDIA HEALTH, INC. METRIX AIR; BLOOD GLUCOSE SYSTEM

Model Number	METRIX AIR
Medical Device Problem Code	High Test Results (2457)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	11/06/2016
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).Product does not return for evaluation yet.Most likely underlying root cause of malfunction: user had an inaccurate reference.
Event or Problem Description
Costumer reported complaint for high blood glucose test results.The customer is concerned with tests results from meter to meter comparison of test result reported of 515 mg/dl using truemetrix air meter and test result reported of 319 mg/dl using another device.The customer's expected fasting blood glucose test result range is 200 - 250 mg/dl.The customer feels well and did not report any symptoms.Medical attention is not reported as a result of the actual blood glucose results.During the call on (b)(6) 2016, a back to back blood test was performed by the customer non-fasting and produced test results of 187 mg/dl and 250 mg/dl.The product is stored according to specification in the living room.The test strip lot manufacturer's expiration date is 08/31/2017 and customer stated open vial date is "about 5 days ago." the meter memory was reviewed for previous test result history: (b)(6).Memory concerns:high results.Customer states that obtained a reading of 515mg/dl fasting on the meter.Customer became worried and stated within 10 minutes customer tested with a neighbor's meter and obtained a result of 319mg/dl.
Additional Manufacturer Narrative
(b)(4).Investigation completed and product evaluated with no defect found on returned meter.Most likely underlying root cause of malfunction:user had an inaccurate reference.
Event or Problem Description
Costumer reported complaint for high blood glucose test results.The customer is concerned with tests results from meter to meter comparison of test result reported of 515 mg/dl using truemetrix air meter and test result reported of 319 mg/dl using another device.The customer's expected fasting blood glucose test result range is 200 - 250 mg/dl.The customer feels well and did not report any symptoms.Medical attention is not reported as a result of the actual blood glucose results.During the call on (b)(6) 2016, a back to back blood test was performed by the customer non-fasting and produced test results of 187 mg/dl and 250 mg/dl.The product is stored according to specification in the living room.The test strip lot manufacturer's expiration date is 08/31/2017 and customer stated open vial date is "about 5 days ago." the meter memory was reviewed for previous test result history: (b)(6).Customer states that obtained a reading of 515mg/dl fasting on the meter.Customer became worried and stated within 10 minutes customer tested with a neighbor's meter and obtained a result of 319mg/dl.

• Brand Name: METRIX AIR
• Common Device Name: BLOOD GLUCOSE SYSTEM
• Manufacturer (Section D): TRIVIDIA HEALTH, INC.; 2400 nw 55th court; fort lauderdale FL 33309
• MDR Report Key: 6139356
• Report Number: 1000113657-2016-01939
• Device Sequence Number: 16340342
• Product Code: NBW
• UDI-Device Identifier: 00021292007867
• UDI-Public: (01)00021292007867(17)170831(10)MT1642
• Combination Product (Y/N): N
• Initial Reporter State: OH
• PMA/510(K) Number: K150052
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: consumer
• Initial Reporter Occupation: Other
• Remedial Action: Replace
• Type of Report: Initial,Followup
• Report Date (Section B): 12/15/2016

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 Expiration Date: 08/31/2017
• Device Model Number: METRIX AIR
• Device Catalogue Number: REA4H01-01
• Device Lot Number: MT1642
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 12/01/2016
• Was the Report Sent to FDA?: No
• Event Location: Home
• Type of Report(Section G): FDA Requested
• Initial Date Received by Manufacturer: 11/06/2016
• Supplement Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 12/01/2016
• Supplement Report FDA Received Date: 12/15/2016
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: SECOND THERAPY