MAUDE Adverse Event Report: MEDTRONIC MINIMED INFST MMT-874 SURET PRDGM 10PK 8MM23N; SET, ADMINISTRATION, INTRAVASCULAR

Model Number MMT-874

Device Problem Device Displays Incorrect Message (2591)

Patient Problem No Consequences Or Impact To Patient (2199)

Event Date 05/28/2016

Event Type  malfunction  

Manufacturer Narrative

Note: this is a remediation mdr.Medtronic diabetes implemented revised mdr reportability criteria effective on (b)(6) 2017.Subsequently, medtronic diabetes conducted a two year retrospective review of complaints.This event was retrospectively identified to be reportable based on the revised mdr reportability criteria.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 Description

Customer reported via phone that they received a no delivery alarm.Customer's blood glucose level at the time of the incident was 238 mg/dl.Customer was able to troubleshoot.Customer disconnected at the quick release and attempted to perform a fixed prime.Customer reported that insulin did not exit the infusion set tubing and the pump continued to alarm no delivery.Customer reported that insulin also did not exit when attempting to push it through with a plunger.Customer replaced the infusion set and observed insulin exit the tubing with the same reservoir.The product is expected to be returned.

• Brand Name: INFST MMT-874 SURET PRDGM 10PK 8MM23N
• Type of Device: SET, ADMINISTRATION, INTRAVASCULAR
• Manufacturer (Section D): MEDTRONIC MINIMED; 18000 devonshire st.; northridge CA 91325 1219
• Manufacturer (Section G): MEDTRONIC MINIMED; 18000 devonshire st.; northridge CA 91325 1219
• Manufacturer Contact: gerwin de graaff ; 18000 devonshire st.; northridge, CA 91325-1219
• MDR Report Key: 7198135
• MDR Text Key: 97580092
• Report Number: 2032227-2018-00712
• Device Sequence Number: 1
• Product Code: FPA
• UDI-Device Identifier: 20643169441709
• UDI-Public: (01)20643169441709(017)20200115
• Combination Product (y/n): N
• Reporter Country Code: US
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: consumer
• Reporter Occupation: Patient
• Type of Report: Initial
• Report Date: 01/16/2018

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
• Device Operator: Lay User/Patient
• Device Expiration Date: 01/15/2020
• Device Model Number: MMT-874
• Device Catalogue Number: MMT-874
• Device Lot Number: 5097020
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Initial Date Manufacturer Received: 05/28/2016
• Initial Date FDA Received: 01/16/2018
• Date Device Manufactured: 03/05/2015
• Is the Device Single Use?: No
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Unknown
• Patient Sequence Number: 1
• Patient Age: 57 YR
• Patient Weight: 69