MAUDE Adverse Event Report: MEDTRONIC PUERTO RICO OPERATIONS CO. 530G INSULIN PUMP MMT-751RNAL; ARTIFICIAL PANCREAS DEVICE SYSTEM, THRESHOLD SUSPEND

Model Number	MMT-751RNAL
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	07/23/2017
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).Currently it is unknown whether or not the device may have caused or contributed to the event.The device has been returned, but not yet evaluated.Further information will follow once the analysis has been completed.No conclusion can be drawn at this time.
Event or Problem Description
The customer reported via phone call the insulin pump alarmed rf pic failed self test.The customer's blood glucose level was 120 mg/dl at the time of incident.The customer reported lost sensors.During troubleshooting the reoccurring alarm was found in the history.The insulin pump will be returned for analysis.
Additional Manufacturer Narrative
Findings: pump passed displacement test, rewind test, basic occlusion test, prime test, excessive no delivery test, occlusion test, self test and unexpected alarm error test.No alarm noted.Pump passed all operating currents tested within the spec range and passed off no power test.Unit was programmed with test minilink transmitter and the glucose sensor simulator.Unit communicated properly with glucose sensor simulator and display the 100 value properly on display graph.No lost sensor alarm noted.Pump received with cracked reservoir tube lip, cracked case near display window corners and minor scratches on display window noted.A complete analysis and testing of the insulin pump showed that it was functioning properly and passed all functional testing.After testing it was concluded that the device operated within specifications.

• Brand Name: 530G INSULIN PUMP MMT-751RNAL
• 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: 6806107
• Report Number: 2032227-2017-38240
• Device Sequence Number: 1083087
• Product Code: OZO
• UDI-Device Identifier: 00643169507982
• UDI-Public: (01)00643169507982
• Combination Product (Y/N): N
• Initial Reporter State: TN
• 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): 10/26/2017

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: MMT-751RNAL
• Device Catalogue Number: MMT-751RNAL
• Device Lot Number: A3751RNALJ
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 08/03/2017
• Initial Date Received by Manufacturer: 07/23/2017
• Supplement Date Received by Manufacturer: 10/20/2017
• Initial Report FDA Received Date: 08/18/2017
• Supplement Report FDA Received Date: 10/26/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 74 YR
• Patient Weight: 178