MAUDE Adverse Event Report: DEXCOM, INC. DEXCOM G5 MOBILE CONTINUOUS GLUCOSE MONITORING SYSTEM

Model Number	MT22719-PNK
Medical Device Problem Code	Device Displays Incorrect Message (2591)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	12/31/2016
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).The g5 system is associated with product code pqf.
Event or Problem Description
Dexcom was made aware on (b)(6) 2016, that on (b)(6) 2016, the receiver displayed err121.No additional patient or event information is available.No product or data were returned for evaluation.The complaint could not be confirmed.A root cause could not be determined.
Additional Manufacturer Narrative
(b)(4) describe event or problem - additional, device available for evaluation - additional, additional information/device evaluation, device evaluated by manufacturer - additional, event problem and evaluation codes - additional.
Event or Problem Description
The complaint device was returned for evaluation.The device was visually inspected and no defect was found.The receiver log was reviewed and screen error alarms and firmware errors were observed.The reported event of an error icon display was confirmed during log review.A root cause could not be determined.

• Brand Name: DEXCOM G5 MOBILE CONTINUOUS GLUCOSE MONITORING SYSTEM
• Common Device Name: CONTINUOUS GLUCOSE MONITOR
• Manufacturer (Section D): DEXCOM, INC.; 6340 sequence drive; san diego CA 92121
• MDR Report Key: 6277740
• Report Number: 3004753838-2017-10268
• Device Sequence Number: 13717577
• Product Code: MDS
• UDI-Device Identifier: 00386270000262
• UDI-Public: (01)00386270000262(241)MT22719-PNK(10)5216909(17)NA
• Combination Product (Y/N): N
• Initial Reporter State: CA
• Initial Reporter Country: US
• PMA/510(K) Number: P120005
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: consumer
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 12/31/2016

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 Model Number: MT22719-PNK
• Device Catalogue Number: STK-GF-PNK
• Device Lot Number: 5216909
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 01/31/2017
• Type of Report(Section G): FDA Requested
• Initial Date Received by Manufacturer: 12/31/2016
• Supplement Date Received by Manufacturer: Not provided
• Initial Report FDA Received Date: 01/25/2017
• Supplement Report FDA Received Date: 02/14/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 12 YR
• Patient Weight: 44