CREATININE PLUS SYSTEM PACK

Description of Event or Problem

CANCER PATIENT WITH UNSPECIFIED "ILLNESS" WAS HOSPITALIZED BASED ON A CREATININE RESULT OF 13.8 MG/DL FROM THE SUSPECT DEVICE. THE FOLLOWING DAY, AN ALTERNATE METHOD (JAFFE REACTION) WAS USED TO ASSAY THE SAMPLE WITH A RESULT OF 2.0 MG/DL. THE TREATING PHYSICIAN BELIEVED THE 2.0 MG/DL VALUE BETTER FIT THE PATIENT'S CONDITION. THE PATIENT WAS TRANSFUSED WITH 2 UNITS OF BLOOD, BUT THE REPORTING TECHNICIAN DID NOT KNOW IF THIS WAS BEFORE OR AFTER THE CREATININE TEST.