MAUDE Adverse Event Report: MEDTRONIC PUERTO RICO OPERATIONS CO. SENSOR ENLITE MMT-7008B; ARTIFICIAL PANCREAS DEVICE SYSTEM, THRESHOLD SUSPEND

Model Number	MMT-7008B
Health Effect - Clinical Code	Hyperglycemia (1905)
Date of Event	06/21/2017
Type of Reportable Event	Serious Injury
Additional Manufacturer Narrative
Currently it is unknown whether or not the device may have caused or contributed to the event as no product has been returned.The device will be returned for analysis and further information will follow once the analysis has been completed.No conclusion can be drawn at this time.
Event or Problem Description
The customer's father reported via phone call that his daughter experienced sensor glucose versus blood glucose differences with threshold suspend.Customer's sensor glucose was 40 and blood glucose was 450 mg/dl.Customer was advised that their blood glucose and sensor glucose were not within acceptable range.The caller declined troubleshooting for any other issues.The insulin pump will not be returning for analysis.The sensor will be returning for analysis.
Additional Manufacturer Narrative
Inspected one opened/used sensor and performed continuity resistance test found sensor passed per specifications and performed the sensor initialization test using a new lab transmitter with a 7xx/5xx paradigm insulin pump.Connected the sensor to the transmitter and placed it in 100 bts solution, confirmed the communication icon was displayed and that the transmitter was flashing while connected to the sensor.The sensor functioned properly.Found cannula bent unable to confirm customer received sensor in said condition due to customer return sensors opened/used.Cannot performed bts test as the sensor is beyond its expiration date.

• Brand Name: SENSOR ENLITE MMT-7008B
• Common Device Name: ARTIFICIAL PANCREAS DEVICE SYSTEM, THRESHOLD SUSPEND
• Manufacturer (Section D): MEDTRONIC PUERTO RICO OPERATIONS CO.; ceiba norte ind. park #50 road; juncos 00777 -386
• MDR Report Key: 6721659
• Report Number: 2032227-2017-29318
• Device Sequence Number: 13837700
• Product Code: OZO
• UDI-Device Identifier: 00643169646407
• UDI-Public: (01)00643169646407(017)20171021
• Combination Product (Y/N): N
• Initial Reporter State: CO
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: consumer
• Initial Reporter Occupation: Patient
• Type of Report: Initial,Followup
• Report Date (Section B): 03/15/2018

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Lay User/Patient
• Device Expiration Date: 10/21/2017
• Device Model Number: MMT-7008B
• Device Catalogue Number: MMT-7008B
• Device Lot Number: HG1T963H12
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 08/25/2017
• Initial Date Received by Manufacturer: 06/21/2017
• Supplement Date Received by Manufacturer: 03/05/2018
• Initial Report FDA Received Date: 07/18/2017
• Supplement Report FDA Received Date: 03/15/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other
• Patient Age: 8 YR
• Patient Weight: 62