MAUDE Adverse Event Report: DEXCOM, INC. DEXCOM G4 PLATINUM PEDIATRIC CONTINUOUS GLUCOSE MONITORING SYSTEM

Model Number	MT22430
Medical Device Problem Code	Defective Alarm (1014)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	03/13/2017
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).
Event or Problem Description
Dexcom was made aware on (b)(6) 2017 that on (b)(6) 2017 the receiver had no vibration.No additional event or patient information is available.The receiver was returned for evaluation.An external visual inspection was performed and passed.The receiver data log was downloaded and reviewed; however, no issues related to the customer's complaint were observed in the course of the log review.Global receiver functional test was performed and failed, but results are not related to the reported event.A manual sound drop test was performed and passed.The reported event of no vibration was not confirmed.A root cause could not be determined.
Additional Manufacturer Narrative
(b)(4).

• Brand Name: DEXCOM G4 PLATINUM PEDIATRIC 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: 6462389
• Report Number: 3004753838-2017-29614
• Device Sequence Number: 591183
• Product Code: MDS
• UDI-Device Identifier: 10386270000078
• UDI-Public: (01)10386270000078(241)STK-KD-001(10)5159486
• Combination Product (Y/N): N
• Initial Reporter State: NC
• 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
• Remedial Action: Recall
• Type of Report: Initial,Followup
• Report Date (Section B): 03/13/2017

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 Model Number: MT22430
• Device Catalogue Number: STK-KD-001
• Device Lot Number: 5159486
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 03/27/2017
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 03/13/2017
• Supplement Date Received by Manufacturer: 08/02/2017
• Initial Report FDA Received Date: 04/05/2017
• Supplement Report FDA Received Date: 08/02/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• If action reported to FDA under 21 USC 360i(g), list FDA-assigned Recall Number or include a statement: 3004753838-02/29/16-001C
• Patient Sequence Number: 1
• Patient Age: 14 YR