inforMED
MalfunctionCEO

PHOS2 PHOSPHATE (INORGANIC) VER.2

Received Mar 8, 2021 · Event occurred Feb 11, 2021

Report 1823260-2021-00697 · MDR key 11438858

Device

Generic name

Phosphomolybdate (colorimetric), Inorganic Phosphorus

Manufacturer

Roche Diagnostics

Model number

NA

Catalog number

03183793122

Lot number

48358501

Product problems

  • High Test Results
  • Low Test Results
  • High Test Results
  • Low Test Results

Patient

80 YR

  • No Clinical Signs, Symptoms or Conditions
  • No Clinical Signs, Symptoms or Conditions

Narrative

Additional Manufacturer Narrative

UNIQUE IDENTIFIER (UDI) # (B)(4). THE CUSTOMER FOUND A DEFECTIVE REAGENT PACK AND THAT THE PROBE TIP WAS BLOCKED WITH PLASTIC. THE PROBE WAS REPLACED. PRECISION STUDIES WERE PERFORMED AND WERE ACCEPTABLE. THE INVESTIGATION IS ONGOING.

Description of Event or Problem

THE INITIAL REPORTER COMPLAINED OF A QUESTIONABLE PHOS GEN.2, RESULT FOR 1 PATIENT SAMPLE, ON A COBAS 6000 C (501) MODULE ANALYZER SERIAL NUMBER (B)(4). THE INITIAL RESULT WAS 1.9 MG/DL AND THE REPEAT RESULT WAS 3.4 MG/DL. THE INITIAL RESULT WAS REPORTED OUTSIDE THE LABORATORY.

Additional Manufacturer Narrative

IT WAS PREVIOUSLY STATED THE CUSTOMER FOUND "THAT THE PROBE TIP WAS BLOCKED WITH PLASTIC. THE PROBE WAS REPLACED. PRECISION STUDIES WERE PERFORMED AND WERE ACCEPTABLE." THIS WAS CORRECTED TO HAVING BEEN FOUND BY THE FIELD SERVICE ENGINEER. THE LAST CALIBRATION WAS PERFORMED ON (B)(6) 2020 WITH ACCEPTABLE RESULTS. NO FURTHER ISSUES WERE REPORTED AFTER THE SERVICE VISIT. THE INVESTIGATION DETERMINED THAT THE ISSUE FOUND BY THE FIELD SERVICE ENGINEER WAS THE ROOT CAUSE OF THE EVENT.