MAUDE Adverse Event Report: DEXCOM, INC. DEXCOM G4 PLATINUM CONTINUOUS GLUCOSE MONITORING SYSTEM

Model Number	MT20649-BLU
Medical Device Problem Code	Unable to Obtain Readings (1516)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	01/02/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).
Event or Problem Description
Dexcom as made aware on (b)(4) 2019, that on (b)(6) 2019, an err hw rf, err 67, and err 189 was displayed on the receiver.No product or data was not available for evaluation.Confirmation of the error icon and a probable cause could not be determined.No additional event or patient information is available.
Additional Manufacturer Narrative
(b)(4).
Event or Problem Description
The receiver was returned for evaluation.An external visual inspection was performed and passed.A receiver charge and boot test was performed and passed.The receiver data log was downloaded for review and hardware and firmware errors along with ¿screen error alarm¿ were observed.The receiver case was opened for an internal visual inspection and it passed.The reported event of an error icon display was confirmed during log review.A probable cause could not be determined.

• Brand Name: DEXCOM G4 PLATINUM CONTINUOUS GLUCOSE MONITORING SYSTEM
• Common Device Name: CONTINUOUS GLUCOSE MONITOR
• Manufacturer (Section D): DEXCOM, INC.; 6340 sequence dr.; san diego CA 92121
• MDR Report Key: 8262030
• Report Number: 3004753838-2019-009871
• Device Sequence Number: 19194625
• Product Code: MDS
• UDI-Device Identifier: 10386270000092
• UDI-Public: 10386270000092
• Combination Product (Y/N): N
• Initial Reporter State: NJ
• Initial Reporter Country: US
• PMA/510(K) Number: P120005
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: consumer
• Initial Reporter Occupation: Other
• Type of Report: Initial,Followup
• Report Date (Section B): 01/18/2019

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: MT20649-BLU
• Device Catalogue Number: STK-GL-BLU
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 03/02/2019
• Was the Report Sent to FDA?: No
• Initial Date Received by Manufacturer: 01/02/2019
• Supplement Date Received by Manufacturer: 03/26/2019
• Initial Report FDA Received Date: 01/18/2019
• Supplement Report FDA Received Date: 04/19/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 63 YR