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

Model Number	TRUEMETRIX
Medical Device Problem Codes	Incorrect Or Inadequate Test Results (2456); Low Test Results (2458)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	08/21/2017
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
Internal report # (b)(4).Product not yet returned for evaluation.Most likely underlying root cause: mlc-20 user's test strip had poor storage (bathroom) test strip udi# (b)(4).
Event or Problem Description
Consumer reported complaint for erratic and low blood glucose test results.The customer is concerned with test results from results obtained of 42, 121 and 103 mg/dl.Customer was concerned results were erratic and that the 42 mg/dl was too low.The customer's expected fasting blood glucose test result range is 78 - 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 not performed by the customer.The product is not stored according to specification and is stored in the bathroom.The test strip lot manufacturer's expiration date is 08/27/2018 and open vial date was undisclosed.The meter memory was reviewed for previous test result history: (b)(6).Memory concerns:customer is concerned with fasting erratic results 42, 121, 103, and 84mg/dl.Customer is also concerned that 42mg/dl is too low.
Additional Manufacturer Narrative
(b)(4).Returned meter evaluated with no defect found.Test strips not returned for evaluation most likely underlying root cause: mlc-20 user's test strip had poor storage (bathroom.) test strip udi# (b)(4).
Event or Problem Description
Consumer reported complaint for erratic and low blood glucose test results.The customer is concerned with test results from results obtained of 42, 121 and 103 mg/dl.Customer was concerned results were erratic and that the 42 mg/dl was too low.The customer's expected fasting blood glucose test result range is 78 - 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 not performed by the customer.The product is not stored according to specification and is stored in the bathroom.The test strip lot manufacturer's expiration date is 08/27/2018 and open vial date was undisclosed.The meter memory was reviewed for previous test result history: (b)(6).Memory concerns:customer is concerned with fasting erratic results 42, 121, 103, and 84mg/dl.Customer is also concerned that 42mg/dl is too low.

• Brand Name: TRUEMETRIX
• Common Device Name: BLOOD GLUCOSE SYSTEM
• Manufacturer (Section D): TRIVIDIA HEALTH, INC.; 2400 nw 55th court; fort lauderdale FL 33309
• MDR Report Key: 6848021
• Report Number: 1000113657-2017-01689
• Device Sequence Number: 1430900
• Product Code: NBW
• UDI-Device Identifier: 00041220001286
• UDI-Public: (01)00041220001286
• Combination Product (Y/N): N
• Initial Reporter State: TX
• PMA/510(K) Number: K140100
• 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,Followup
• Report Date (Section B): 09/20/2017

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: 08/27/2018
• Device Model Number: TRUEMETRIX
• Device Catalogue Number: RE4H01-81
• Device Lot Number: MU2372
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 09/07/2017
• Was the Report Sent to FDA?: No
• Event Location: Home
• Initial Date Received by Manufacturer: 08/21/2017
• Supplement Date Received by Manufacturer: 08/21/2017
• Initial Report FDA Received Date: 09/07/2017
• Supplement Report FDA Received Date: 09/20/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1