MAUDE Adverse Event Report: MEDTRONIC MINIMED PARADIGM REAL-TIME INSULIN INFUSION PUMP MMT-722NALL; PUMP, INFUSION, INSULIN, TO BE USED WITH INVASIVE GLUCOSE SENSOR

Model Number	MMT-722NAL
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	12/15/2017
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
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 that the insulin pump alarmed compromised force sensor system.The customer¿s blood glucose level was 136 mg/dl at the time of the incident.It was reported that the customer tried to prime the insulin pump and was getting an compromised force sensor system error message and it will not clear out.Customer stated that the drive support cap was protruded.The customer was advised to discontinue use of the pump and to revert to back up plan per health care professional instructions.The customer was advised the insulin pump will need to be replaced.The insulin pump will be returned for analysis.
Additional Manufacturer Narrative
Compromised force sensor system alarm during basic occlusion test due to loose/protruded drive support disk.Unable to perform occlusion test and excessive no delivery test due to loose drive support disk.Unit was received with minor scratched display window, cracked case at display window corner, cracked battery tube threads, partially broken reservoir tube lip, broken belt clip slot, stained end cap sticker and stained address/serial number label.

• Brand Name: PARADIGM REAL-TIME INSULIN INFUSION PUMP MMT-722NALL
• Common Device Name: PUMP, INFUSION, INSULIN, TO BE USED WITH INVASIVE GLUCOSE SENSOR
• Manufacturer (Section D): MEDTRONIC MINIMED; 18000 devonshire st.; northridge CA 91325 1219
• MDR Report Key: 7149712
• Report Number: 2032227-2017-77558
• Device Sequence Number: 16344031
• Product Code: OYC
• UDI-Device Identifier: 00613994223722
• UDI-Public: (01)00613994223722(017)20091231
• Combination Product (Y/N): N
• Initial Reporter State: IL
• 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): 04/16/2018

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: 12/31/2009
• Device Model Number: MMT-722NAL
• Device Catalogue Number: MMT-722NAL
• Device Lot Number: A000093813
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 12/21/2017
• Initial Date Received by Manufacturer: 12/15/2017
• Supplement Date Received by Manufacturer: 03/27/2018
• Initial Report FDA Received Date: 12/27/2017
• Supplement Report FDA Received Date: 04/16/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 48 YR
• Patient Weight: 215