Brand Name | PUMP MMT-1715KM 630G 3ML BLACK MEDI |
Type of Device | ARTIFICIAL PANCREAS DEVICE SYSTEM, THRESHOLD SUSPEND |
Manufacturer (Section D) |
MEDTRONIC PUERTO RICO OPERATIONS CO. |
ceiba norte ind. park #50 road |
juncos 00777 -386 |
|
Manufacturer (Section G) |
MEDTRONIC PUERTO RICO OPERATIONS CO. |
ceiba norte ind. park #50 road |
|
juncos 00777 -386 |
|
Manufacturer Contact |
gerwin
de graaff
|
ceiba norte ind. park #50 road |
juncos 00777--386
|
8185464805
|
|
MDR Report Key | 8606742 |
MDR Text Key | 144924593 |
Report Number | 3004209178-2019-96773 |
Device Sequence Number | 1 |
Product Code |
OZO
|
UDI-Device Identifier | 00643169873834 |
UDI-Public | (01)00643169873834 |
Combination Product (y/n) | N |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
consumer,other |
Type of Report
| Initial |
Report Date |
05/13/2019 |
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
|
Device Operator |
Lay User/Patient
|
Device Model Number | MMT-1715KM |
Device Catalogue Number | MMT-1715KM |
Device Lot Number | HG2G7KN |
Was Device Available for Evaluation? |
No
|
Initial Date Manufacturer Received |
05/06/2019 |
Initial Date FDA Received | 05/14/2019 |
Date Device Manufactured | 04/13/2018 |
Is the Device Single Use? |
No
|
Is This a Reprocessed and Reused Single-Use Device? |
No
|
Type of Device Usage |
Unknown
|
Patient Sequence Number | 1 |
Treatment | FRN-RSVR, OZO-UNK-SNSR, UNOMED INF SET. |
Patient Outcome(s) |
Hospitalization;
|
Patient Age | 19 YR |
Patient Weight | 208 |