inforMED
MalfunctionJIL

COBAS U PACK

Received May 14, 2020 · Event occurred Apr 28, 2020

Report 1823260-2020-01226 · MDR key 10058243

Device

Generic name

Urine Test Strip

Manufacturer

Roche Diagnostics

Model number

NA

Catalog number

06334601001

Lot number

ASKU

Product problems

  • False Positive Result
  • False Positive Result

Patient

Not reported

  • No Consequences Or Impact To Patient
  • No Consequences Or Impact To Patient

Narrative

Additional Manufacturer Narrative

THE REPORTER TRIED REMOVING THE COBAS U PACK MANUALLY, BUT COULD NOT DO IT. THE REPORTER LATER NOTED THAT THEY HAD INSTALLED A DAMAGED COBAS U PACK BY MISTAKE. THE REPORTER LATER WAS ABLE TO REMOVE THIS PACK AND THE ANALYZER WAS WORKING AFTER THIS. THE AFFECTED COBAS U PACK WAS THROWN IN THE TRASH. PHONE NUMBER WAS PROVIDED AS (B)(6). THIS EVENT OCCURRED IN (B)(6).

Description of Event or Problem

THE INITIAL REPORTER STATED THEY RECEIVED DISCREPANT NITRITE RESULTS FOR AN UNSPECIFIED NUMBER OF PATIENT SAMPLES TESTED WITH A COBAS U PACK ON A COBAS U 601 URINE ANALYZER. INCORRECT RESULTS WERE REPORTED OUTSIDE OF THE LABORATORY. THE ANALYZER ALSO INDICATED THERE WAS AN ERROR WITH THE COBAS U PACK. THE REPORTER STATED SHE RAN QUALITY CONTROL MATERIAL AND PATIENT SAMPLES AND ALL RESULTED WITH POSITIVE VALUES FOR NITRITE. THE REPORTER REPEATED THE PATIENT SAMPLES AND CONTROL AND RECEIVED NEGATIVE NITRITE VALUES. THE REPORTER BELIEVES ALL PATIENT SAMPLES AND CONTROL WERE INITIALLY FALSE POSITIVE. THE U 601 ANALYZER SERIAL NUMBER IS (B)(4).

Additional Manufacturer Narrative

THE INVESTIGATION WAS UNABLE TO DETERMINE A ROOT CAUSE.