MAUDE Adverse Event Report: MEDTRONIC PUERTO RICO OPERATIONS CO. 530G INSULIN PUMP MMT-751LNAL; ARTIFICIAL PANCREAS DEVICE SYSTEM, THRESHOLD SUSPEND

Model Number	MMT-751LNAL
Medical Device Problem Codes	Display or Visual Feedback Problem (1184); Mechanical Problem (1384); Device Difficult to Program or Calibrate (1496); Obstruction of Flow (2423); Battery Problem (2885); Patient Device Interaction Problem (4001)
Health Effect - Clinical Code	No Consequences Or Impact To Patient (2199)
Date of Event	11/18/2019
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.No conclusion can be drawn at this time.We therefore consider this report complete to the best of our knowledge.
Event or Problem Description
Customer reported via phone call that buttons stopped responding on insulin pump, the screen was scratched and scrapped which affect ability to see screen.Customer¿s current blood glucose was unknown.Customer stated that insulin pump had cracked battery cap, piece broke off, insulin pump was slower to rewind, had unexplained no delivery alarms, decreased battery life.Insulin pump will not be returned for analysis.
Additional Manufacturer Narrative
Device received with broken battery cap and minor scratches on lcd display window noted.The test reservoir p-cap was able to lock in place.Device received with no button response at bolus, esc, act, up arrow and down arrow button due to unlocked connector on lcd board and flattened dome switch on up arrow button noted.Unable to perform displacement test, self test, off no power test, a21 error test, stop current test, run current test, rewind test, basic occlusion test, prime/a33 test, excessive no delivery test and occlusion test or verify no delivery/occlusion alarm, rewind anomaly, missing segments and charge battery anomaly due to keypads not responsive.(b)(4).

• Brand Name: 530G INSULIN PUMP MMT-751LNAL
• 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: 9352847
• Report Number: 2032227-2019-120805
• Device Sequence Number: 19433694
• Product Code: OZO
• UDI-Device Identifier: 00643169933200
• UDI-Public: (01)00643169933200
• Combination Product (Y/N): N
• Initial Reporter State: MI
• 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
• Report Date (Section B): 07/20/2020

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 Model Number: MMT-751LNAL
• Device Catalogue Number: MMT-751LNAL
• Device Lot Number: A5751LNALJ
• Was Device Available for Evaluation?: Device Returned to Manufacturer
• Date Returned to Manufacturer: 12/09/2019
• Initial Date Received by Manufacturer: 11/18/2019
• Supplement Date Received by Manufacturer: 07/20/2020
• Initial Report FDA Received Date: 11/21/2019
• Supplement Report FDA Received Date: 07/21/2020
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 53 YR