MAUDE Adverse Event Report: ROCHE DIABETES CARE, INC. ACCU-CHEK ® COMPACT TEST DRUM; BLOOD GLUCOSE MONITORING TEST STRIPS

Model Number	05599415160
Medical Device Problem Code	Incorrect, Inadequate or Imprecise Result or Readings (1535)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	12/09/2019
Type of Reportable Event	Malfunction
Event or Problem Description
It was reported the patient received the following results within 15 minutes: 180 mg/dl and 95 mg/dl.

• Brand Name: ACCU-CHEK ® COMPACT TEST DRUM
• Common Device Name: BLOOD GLUCOSE MONITORING TEST STRIPS
• Manufacturer (Section D): ROCHE DIABETES CARE, INC.; 9115 hague road; indianapolis IN 46250 0457
• MDR Report Key: 9511858
• Report Number: 3011393376-2019-04679
• Device Sequence Number: 3542087
• Product Code: NBW
• UDI-Device Identifier: 00075537474198
• UDI-Public: 00075537474198
• Combination Product (Y/N): N
• Initial Reporter State: NJ
• Initial Reporter Country: US
• PMA/510(K) Number: K031755
• 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): 03/06/2020

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 Expiration Date: 08/31/2020
• Device Model Number: 05599415160
• Device Catalogue Number: 05599415160
• Device Lot Number: 20818871
• Was Device Available for Evaluation?: No
• Initial Date Received by Manufacturer: 12/09/2019
• Supplement Date Received by Manufacturer: 02/20/2020
• Initial Report FDA Received Date: 12/23/2019
• Supplement Report FDA Received Date: 03/06/2020
• Patient Sequence Number: 1
• Patient Age: 70 YR
• Patient Weight: 77