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Adverse Event Report

ELI LILLY AND CO. HUMAPEN ERGO, BURG/CLEAR PEN INJECTOR   back to search results
Model Number MS8930
Device Problem Component(s), broken
Event Type  Malfunction  
Manufacturer Narrative

Final examination of the complaint device by product delivery systems revealed the two engagement tabs on the clear cartridge holder had been intentionally removed.

 
Event Description

This device case, reported by a non-health care professional, concerns a pt. The pt was using a pen injection device (humapen ergo-burgundy/clear cartridge holder/model ms8930) to deliver insulin for the treatment of diabetes. The pt had been using the humapen ergo for approx three years. Prior to complaint device the pt had used humapen ergo (opaque cartridge holder). The pt rec'd two pen injection devices (humapen ergo-burgundy/clear cartridge holder/model ms8930) directly from the mfr. The rptr returned the pen injection device with the complaint: the pt had a new pen with burgundy-clear cartridge holderand when putting a new cartridge in, the screw did not go back. The lead screw was in contact with the bung in the cartridge, but no insulin was coming out. No adverse drug event is associated with the complaint. The mfr rec'd the complaint device on mar-2002. Initial examination revealed the general condition of the pen was good. No defects were observed. Final examination of the complaint device by product delivery systems on apr-2002 revealed the two engagement tabs on the clear cartridge holder had been intentionally removed. Further info rec'd from the initial rptr revealed the pt had not taken the pen apart or removed any part of the pen prior to its return. The reporter stated that nothing appeared to be missing from the pen prior to returning the device for investigation. Update apr-2002: corrections made to case. Initial analysis by pds corrected to apr-2002.

 
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Brand NameHUMAPEN ERGO, BURG/CLEAR
Type of DevicePEN INJECTOR
Baseline Brand NameHUMAPEN ERGO, BURG/CLEAR
Baseline Generic NamePEN INJECTOR
Baseline Catalogue NumberNI
Baseline Model NumberMS8930
Baseline Device 510(K) Number
Baseline Device PMA Number
Manufacturer (Section F)
ELI LILLY AND CO.
lilly corporate center
indianapolis IN 46285
Manufacturer (Section D)
ELI LILLY AND CO.
lilly corporate center
indianapolis IN 46285
Manufacturer Contact
lilly corporate center
indianapolis , IN 46285
(317) 276 -7788
Device Event Key381530
MDR Report Key392502
Event Key370775
Report Number1819470-2002-00016
Device Sequence Number1
Product CodeKZE
Report Source Manufacturer
Source Type Foreign,Consumer
Reporter Occupation NO INFORMATION
Type of Report Initial
Report Date 03/06/2002
1 Device Was Involved in the Event
1 Patient Was Involved in the Event
Date FDA Received05/03/2002
Is This An Adverse Event Report? Yes
Is This A Product Problem Report? Yes
Device Operator Lay User/Patient
Device MODEL NumberMS8930
Device LOT Number40175
Was Device Available For Evaluation? Device Returned To Manufacturer
Date Returned to Manufacturer03/06/2002
Is The Reporter A Health Professional? No
Was the Report Sent to FDA? No
Date Manufacturer Received03/06/2002
Was Device Evaluated By Manufacturer? No Answer Provided
Is The Device Single Use? No
Is the Device an Implant? No
Is this an Explanted Device?
Type of Device Usage Unkown

Database last updated on January 06, 2009

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