MAUDE Adverse Event Report: HTL-STREFA S.A. MEMBER'S MARK PEN NEEDLE; PEN NEEDLES

Model Number	32G X 4MM
Medical Device Problem Code	Material Twisted/Bent (2981)
Health Effect - Clinical Code	No Information (3190)
Type of Reportable Event	Malfunction
Event or Problem Description
The insulin pen doesn't come out due to bent non-patient end.Patient believes she is putting on correctly.She does have poor vision, so she is unaware if the pen needle is bent prior to putting on the pen.
Event or Problem Description
The insulin pen doesn't come out due to bent non-patient end.Patient believes she is putting on correctly.She does have poor vision, so she is unaware if the pen needle is bent prior to putting on the pen.

• Brand Name: MEMBER'S MARK PEN NEEDLE
• Common Device Name: PEN NEEDLES
• Manufacturer (Section D): HTL-STREFA S.A.; adamowek 7; ozorkow, 95-03 5; PL 95-035
• MDR Report Key: 8330338
• Report Number: 9613304-2019-00029
• Device Sequence Number: 59471
• Product Code: FMI
• UDI-Device Identifier: 10078742257720
• UDI-Public: (01)10078742257720(17)230601(10)Y58S9
• Combination Product (Y/N): N
• PMA/510(K) Number: K143437
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: distributor
• Initial Reporter Occupation: Other
• 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 Expiration Date: 06/01/2023
• Device Model Number: 32G X 4MM
• Device Catalogue Number: 8930
• Device Lot Number: Y58S9
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 02/05/2019
• Initial Date Received by Manufacturer: 01/17/2019
• Supplement Date Received by Manufacturer: 01/17/2019
• Initial Report FDA Received Date: 02/12/2019
• Supplement Report FDA Received Date: 02/27/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1