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

Model Number	TRUEMETRIX
Medical Device Problem Code	Low Test Results (2458)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	12/03/2018
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(manufacturer narrative = t, corrected data = f) internal report # (b)(4).Product not yet returned for evaluation.Most likely underlying root cause: mlc-55 - user had an inaccurate reference: competitor's meter: the end user is comparing results obtained from trividia's bgm system to the results from a competitor's bgm system.Test strip udi# (b)(4).Note: manufacturer contacted customer on 12/17/2018 in a follow-up call to ensure that the replacement products resolved the initial concern; customer stated that they received the replacement product; however, they didn't start to use it yet.No symptoms or medical attention reported since the last call.
Event or Problem Description
Consumer reported complaint for low blood glucose test results.Daughter is calling on behalf of the customer.The customer is concerned with all the tests results obtained.The expected non- fasting blood glucose test result range is 150 to 200mg/dl.The customer did not report symptoms.Medical attention is not reported as a result of the actual blood glucose results.The product is stored according to specification in the bedroom.During the call on (b)(6) 2018, a blood test was not performed by the customer (declined).The test strip lot manufacturer's expiration date is 03/31/2020 and open vial date is 11/26/2018.The meter memory was reviewed for previous test result history: (b)(6).
Event or Problem Description
Consumer reported complaint for low blood glucose test results.Daughter is calling on behalf of the customer.The customer is concerned with all the tests results obtained.The expected non- fasting blood glucose test result range is 150 to 200mg/dl.The customer did not report symptoms.Medical attention is not reported as a result of the actual blood glucose results.The product is stored according to specification in the bedroom.During the call on 12/03/2018, a blood test was not performed by the customer (declined).The test strip lot manufacturer's expiration date is 03/31/2020 and open vial date is 11/26/2018.The meter memory was reviewed for previous test result history: result 1 :127mg/dl, date: (b)(6) 2020, time:05:26 pm, n/fasting; result 2 :105mg/dl, date: (b)(6) 2020, time:12:56 pm, n/fasting; result 3 :113mg/dl, date: (b)(6) 2020, time:12:54pm, n/fasting; result 4 :106mg/dl, date: (b)(6) 2020, time:12:53pm, n/fasting; result 5 :127mg/dl, date: (b)(6) 2020, time:05:26pm, n/fasting.
Additional Manufacturer Narrative
(manufacturer narrative = t, corrected data = f) internal report # (b)(4).Returned meter and returned test strips evaluated with no defects found.Most likely underlying root cause: mlc-55-user had an inaccurate reference: competitor's meter: the end user is comparing results obtained from trividia's bgm system to the results from a competitor's bgm system test strip udi# (b)(4).Note: manufacturer contacted customer on 12/17/2018 in a follow-up call to ensure that the replacement products resolved the initial concern; customer stated that they received the replacement product however they didn't start to use it yet.No symptoms or medical attention reported since the last call.

• 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: 8196986
• Report Number: 1000113657-2018-01283
• Device Sequence Number: 2261578
• Product Code: NBW
• UDI-Device Identifier: 00021292006051
• UDI-Public: (01)00021292006051
• Combination Product (Y/N): N
• Initial Reporter State: LA
• PMA/510(K) Number: K140100
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: other
• Initial Reporter Occupation: Other
• Remedial Action: Replace
• Type of Report: Initial,Followup
• Report Date (Section B): 01/17/2019

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: TRUEMETRIX
• Device Catalogue Number: RE4H01-81
• Device Lot Number: MV2947
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 01/03/2019
• Was the Report Sent to FDA?: No
• Event Location: Home
• Initial Date Received by Manufacturer: 12/03/2018
• Supplement Date Received by Manufacturer: 12/03/2018
• Initial Report FDA Received Date: 12/26/2018
• Supplement Report FDA Received Date: 01/17/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: SECOND THERAPY; SECOND THERAPY