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

Model Number	TRUETRACK
Medical Device Problem Code	Incorrect Or Inadequate Test Results (2456)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	02/14/2017
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).Returned meter evaluated with no defect found.Test strips not returned for evaluation.Most likely underlying root cause of malfunction: user had an inaccurate reference.
Event or Problem Description
Consumer reported complaint for erratic blood glucose test results.The customer is concerned with tests results from results obtained of 255 and 94 mg/dl.The customer's expected fasting blood glucose test result range is 90 - 110 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) 2017, a back to back blood test was performed by the customer non-fasting and produced test results of 69 mg/dl and 81 mg/dl using truetrack meter.The customer stated she was not concerned with the results of her back to back test 69 mg/dl and 81 mg/dl; she had just eaten and didn't feel the machine was giving her an accurate reading.She stated she was feeling well and had no symptoms of hypoglycemia.The product is stored according to specification.The test strip lot manufacturer's expiration date is 07/31/2018 and open vial date is (b)(6) 2017.The meter memory was reviewed for previous test result history: 255mg/dl (b)(6)2017 03:06 pm fasting: yes; 249mg/dl (b)(6) 2017 03:04 pm fasting: yes; 94mg/dl (b)(6) 2017 02:59 pm fasting: yes; 104mg/dl (b)(6) 2017 02:58 pm fasting: yes; 5:106mg/dl (b)(6) 2017 01:57 pm fasting: yes.Memory concerns: the customer is concerned with 255 mg/dl and 94 mg/dl.

• Brand Name: TRUETRACK
• Common Device Name: BLOOD GLUCOSE SYSTEM
• Manufacturer (Section D): TRIVIDIA HEALTH, INC.; 2400 nw 55th court; fort lauderdale FL 33309
• MDR Report Key: 6391393
• Report Number: 1000113657-2017-00456
• Device Sequence Number: 10861617
• Product Code: NBW
• UDI-Device Identifier: 00021292008932
• UDI-Public: (01)00021292008932(17)180731(10)RT4868
• Combination Product (Y/N): N
• Initial Reporter State: GA
• PMA/510(K) Number: K032657
• 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
• Report Date (Section B): 03/09/2017

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: 07/31/2018
• Device Model Number: TRUETRACK
• Device Catalogue Number: A4H01-81
• Device Lot Number: RT4868
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 02/28/2017
• Was the Report Sent to FDA?: No
• Event Location: Home
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/14/2017
• Initial Report FDA Received Date: 03/09/2017
• 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