MAUDE Adverse Event Report: MEDTRONIC PUERTO RICO OPERATIONS CO. 530G INSULIN PUMP MMT-551PNAL; ARTIFICIAL PANCREAS DEVICE SYSTEM, THRESHOLD SUSPEND

Model Number	MMT-551PNAL
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	01/14/2018
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 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 or Problem Description
The customer was reported via phone call that, the insulin pump had compromised force sensor system alert and prime rewind anomaly.The blood glucose was 157 mg/dl at the time of the incident.Customer also reported that, the drive support cap was flushed.Troubleshooting determined that, the insulin pump should be replaced.The customer advised to discontinue use of the pump and revert to a back-up plan.The insulin pump will be returned for analysis.
Additional Manufacturer Narrative
Insulin pump passed the displacement test but compromised force sensor system alarm during the basic occlusion test due to loose or protruded drive support disk.Unable to perform the occlusion, prime or compromised force sensor system and excessive no delivery test or verify prime/fill anomaly due to compromised force sensor system alarm.

• Brand Name: 530G INSULIN PUMP MMT-551PNAL
• 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: 7210932
• Report Number: 3004209178-2018-45203
• Device Sequence Number: 869087
• Product Code: OZO
• UDI-Device Identifier: 00643169507289
• UDI-Public: (01)00643169507289
• Combination Product (Y/N): N
• Initial Reporter State: IA
• 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): 09/28/2018

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 Model Number: MMT-551PNAL
• Device Catalogue Number: MMT-551PNAL
• Device Lot Number: A3551PNALJ
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 02/01/2018
• Initial Date Received by Manufacturer: 01/14/2018
• Supplement Date Received by Manufacturer: 06/29/2018
• Initial Report FDA Received Date: 01/22/2018
• Supplement Report FDA Received Date: 09/28/2018
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 61 YR
• Patient Weight: 103