MAUDE Adverse Event Report: MEDTRONIC PUERTO RICO OPERATIONS CO. KIT MMT-1755KR 630G 3ML V4.10 EN RECERT; ARTIFICIAL PANCREAS DEVICE SYSTEM, THRESHOLD SUSPEND

Model Number	MMT-1755KR
Medical Device Problem Codes	No Display/Image (1183); Power Problem (3010)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	06/28/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
(b)(4).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
The customer reported via phone call that the insulin pump had replace battery alarm but when he changed the battery the screen was not turning back on.Customer's blood glucose value was unknown at the time of the incident.Customer was tried 3 different fresh new batteries but it's still not working.Customer stated the screen turns off when he clean the battery compartment.Customer stated that he keeps getting the insert new battery alert even if he changed the battery but it went to a blank display again after seeing the insert new battery alert.Customer stated the contacts on the battery cap are neither missing nor damaged.Customer stated battery compartment was neither damaged nor corroded.Customer stated the spring was neither damaged nor corroded.The device will be returned for analysis.

• Brand Name: KIT MMT-1755KR 630G 3ML V4.10 EN RECERT
• Common Device Name: ARTIFICIAL PANCREAS DEVICE SYSTEM, THRESHOLD SUSPEND
• Manufacturer (Section D): MEDTRONIC PUERTO RICO OPERATIONS CO.; ceiba norte ind. park #50 road; juncos 00777 -386
• MDR Report Key: 8766469
• Report Number: 2032227-2019-26332
• Device Sequence Number: 19342341
• Product Code: OZO
• UDI-Device Identifier: 00763000179632
• UDI-Public: (01)00763000179632(17)211213
• Combination Product (Y/N): N
• Initial Reporter State: AZ
• 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): 07/08/2019

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: 12/13/2021
• Device Model Number: MMT-1755KR
• Device Catalogue Number: MMT-1755KR
• Device Lot Number: HG31FGN
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 06/28/2019
• Initial Report FDA Received Date: 07/08/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 69 YR
• Patient Weight: 165