MAUDE Adverse Event Report: MEDTRONIC MINIMED INFST MMT-943T MIO 2PK 6MM 23IN BLUE; SET, ADMINISTRATION, INTRAVASCULAR

Model Number	MMT-943T
Medical Device Problem Code	Break (1069)
Health Effect - Clinical Code	Hyperglycemia (1905)
Date of Event	04/23/2019
Type of Reportable Event	Serious Injury
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
Customer reported via phone call that they had issues with their infusion sets.The customer's blood glucose at the time of the incident was 474 mg/dl.The customer did not provide any information on treatment of the blood glucose levels.The customer stated that they inserted a set and when they took it off the skin the cannula was not in the body.The customer was assisted with having their infusion sets replaced.

• Brand Name: INFST MMT-943T MIO 2PK 6MM 23IN BLUE
• Common Device Name: SET, ADMINISTRATION, INTRAVASCULAR
• Manufacturer (Section D): MEDTRONIC MINIMED; 18000 devonshire st.; northridge CA 91325 1219
• MDR Report Key: 8567075
• Report Number: 2032227-2019-03662
• Device Sequence Number: 11327796
• Product Code: FPA
• UDI-Device Identifier: 05705244020559
• UDI-Public: (01)05705244020559(17)211001(10)5260936
• Combination Product (Y/N): N
• Initial Reporter State: WV
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: consumer
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 04/30/2019

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Lay User/Patient
• Device Expiration Date: 10/01/2021
• Device Model Number: MMT-943T
• Device Catalogue Number: MMT-943T
• Device Lot Number: 5260936
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 04/23/2019
• Initial Report FDA Received Date: 04/30/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other
• Patient Age: 39 YR