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

Model Number	METRIX AIR
Medical Device Problem Code	High Test Results (2457)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	09/26/2017
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: mlc-58-user had an inaccurate reference: self: the person is using themselves as the reference or how they feel at the time they run the blood test.
Event or Problem Description
Consumer reported complaint for high blood glucose test results.The customer is concerned with test results from meter memory of 202, 402, 197, 263 and 175 mg/dl (402 and 263 are non-fasting).The customer's expected fasting blood glucose test result range is 100 - 120 mg/dl; a non-fasting range was not provided.The customer is using proper testing technique.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 fasting and produced test results of 157 mg/dl and 170 mg/dl using truemetrix air meter.The product is stored according to specification in the bedroom.The test strip lot manufacturer's expiration date is 11/30/2018 and open vial date is (b)(6) 2017.The meter memory was reviewed for previous test result history: result 1 : 202 mg/dl date: (b)(6) 2017 time: 9:21am fasting ; result 2 : 402 mg/dl date: (b)(6) 2017 time: 10:04pm non- fasting; result 3 : 197 mg/dl date: (b)(6) 2017 time: 8:42am fasting ; result 4 : 263 mg/dl date: (b)(6) 2017 time: 8:05pm non- fasting; result 5 : 175 mg/dl date: (b)(6) 2017 time: 7:09am fasting ; customer is concerned with all of the results.

• Brand Name: METRIX AIR
• Common Device Name: BLOOD GLUCOSE SYSTEM
• Manufacturer (Section D): TRIVIDIA HEALTH, INC.; 2400 nw 55th court; fort lauderdale FL 33309
• MDR Report Key: 6949905
• Report Number: 1000113657-2017-01808
• Device Sequence Number: 1141187
• Product Code: NBW
• UDI-Device Identifier: 00021292009472
• UDI-Public: (01)00021292009472(17)181130(10)MU2511
• Combination Product (Y/N): N
• Initial Reporter State: GA
• PMA/510(K) Number: K150052
• 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): 10/13/2017

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 Expiration Date: 11/30/2018
• Device Model Number: METRIX AIR
• Device Catalogue Number: REA4H01-01
• Device Lot Number: MU2511
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 10/03/2017
• Was the Report Sent to FDA?: No
• Event Location: Home
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 09/26/2017
• Initial Report FDA Received Date: 10/13/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1