MAUDE Adverse Event Report: MEDTRONIC MINIMED XMTR MMT-7811NA GST3C LOCKOUT; SENSOR, GLUCOSE, INVASIVE

Model Number	MMT-7811NA
Medical Device Problem Codes	Communication or Transmission Problem (2896); Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Code	Hyperglycemia (1905)
Date of Event	10/15/2019
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 experienced high blood glucose level of 416 mg/dl.Customer's blood glucose value was 416 mg/dl at the time of the call.Customer reported that the high blood glucose levels began on (b)(6) 2019.The customer did not state how they treated hyperglycemia.The customer states that they were changing transmitter at the time.The product was returned for analysis.
Additional Manufacturer Narrative
The event was reported in error.
Additional Manufacturer Narrative
Device was able to charge properly.Device failed to communicate and sync during radio frequency association, problem was isolated to electronic assembly.Unable to perform functional test due to communication anomaly.

• Brand Name: XMTR MMT-7811NA GST3C LOCKOUT
• Common Device Name: SENSOR, GLUCOSE, INVASIVE
• Manufacturer (Section D): MEDTRONIC MINIMED; 18000 devonshire st.; northridge CA 91325 1219
• MDR Report Key: 9201165
• Report Number: 2032227-2019-105535
• Device Sequence Number: 19609799
• Product Code: MDS
• UDI-Device Identifier: 00763000215538
• UDI-Public: (01)00763000215538(17)191122
• Combination Product (Y/N): N
• Initial Reporter State: GA
• 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,Followup,Followup
• Report Date (Section B): 11/04/2020

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: 11/22/2019
• Device Model Number: MMT-7811NA
• Device Catalogue Number: MMT-7811NA
• Device Lot Number: A000665681
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 10/28/2020
• Initial Date Received by Manufacturer: 10/15/2019
• Supplement Date Received by Manufacturer: 04/17/2020; 11/03/2020
• Initial Report FDA Received Date: 10/17/2019
• Supplement Report FDA Received Date: 04/17/2020; 11/04/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 34 YR
• Patient Weight: 145