Recall StatusOpen, Classified
Date Initiated2021-03-15
Product QuantityU.S. Investigational Clinical Study = 1,266 devices
Reason for Recall
Due to a software design issue, under certain conditions, a software fault is detected when a large bolus delivery at quick bolus speed completes. if the user
is not aware of the amount of active insulin and
delivers an additional bolus, there is a risk of insulin
over delivery.
Firm Action
On 03/15/2021, the Recalling Firm sent an "URGENT MEDICAL DEVICE CORRECTION" Notification via regionally approved methods (e.g.
email, registered mail, courier, hand delivery) informing customers that their insulin pump with software version 6.5 that could present pump errors after delivering a large bolus under certain conditions. These errors may occur if All the following conditions are met:
1-The bolus delivery speed is programmed to Quick in the pump settings (default is Standard).
2-The SmartGuard" feature is in use.
3-The pump needs to be on the bolus delivery screen when an auto correction bolus is triggered. Auto corrections are triggered when sensor glucose (SG) is running high and Active Insulin is low.
4-The bolus amount programmed to be delivered is greater than 17.1U.
Note: This can be a single bolus greater than 17.1U or a combination of boluses totaling greater than 17.1U.
If all the above conditions are met, within 2 minutes of bolus delivery completion, the pump initiates Pump error 53, followed by Pump error 23 alarm.
Upon clearing the pump errors, the pump resets and indicates Active Insulin has been cleared. The pump then guides the user to resume operation in Manual Mode. The SmartGuard" status screen indicates the warm-up period has started. After approximately 5 hours, the SmartGuard" feature will be available.
Since Active Insulin will display 0.0 units in the pump after experiencing the pump errors above, if the user is not aware of the amount of active insulin and delivers an additional bolus, there is a risk of insulin over delivery, which may result in low blood sugar (hypoglycemia) or severe hypoglycemia. In rare cases, severe hypoglycemia, if left untreated, may lead to a life-threatening situation. As of January 21, 2021, Medtronic has received no reports of serious patient harm or serious injury related to this issue.
Customers are instructed to:
If their pump screen indicates that Active Insulin has cleare
Root Cause
Software design
Distribution Pattern
U.S.(Clinical): AR, CA, CO, CT, FL, GA, ID, MI, MN, TN, TX, and WA
O.U.S.:
Austria, Bahrain, Belgium, Canary Islands, Chile, Croatia, Czech Republic, Denmark, Egypt, Finland, France, Germany, Gibraltar, Greece, Hungary, Iceland, Ireland, Israel, Italy, Liechtenstein, Luxembourg, Malta, Martinique, Netherlands, New Caledonia, Norway, Poland, Qatar, Reunion, Romania, Slovenia, South Africa, Spain, Sweden, Switzerland, Turkey, and United Kingdom
Official Source
View FDA Recall →Source: FDA Enforcement Report / Recall database. Always confirm against the official FDA record.