MAUDE Adverse Event Report: AUTOSOFT 30; INSET 30 60/13 GREY TCAP

Lot Number	5247475
Medical Device Problem Code	Detachment of Device or Device Component (2907)
Health Effect - Clinical Code	Hyperglycemia (1905)
Type of Reportable Event	Malfunction
Event or Problem Description
Unomedical reference number (b)(4).Event occurred in the united states.The patient stated that in one of the infusion sets, the t-lock was not glued to the tubing and came apart.The patient's blood glucose level was at 300 mg/dl at the time of this event.The patient did not notice any damage when the package was first opened.No further information available.

• Brand Name: AUTOSOFT 30
• Common Device Name: INSET 30 60/13 GREY TCAP
• MDR Report Key: 8635077
• Report Number: 3003442380-2019-01492
• Device Sequence Number: 1822243
• Product Code: FPA
• UDI-Device Identifier: 05705244014602
• UDI-Public: 05705244014602
• Combination Product (Y/N): N
• PMA/510(K) Number: K061374
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: distributor
• Initial Reporter Occupation: Other
• Type of Report: Initial

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: No Information
• Device Expiration Date: 07/01/2021
• Device Lot Number: 5247475
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 02/21/2019
• Initial Report FDA Received Date: 05/23/2019
• Patient Sequence Number: 1