inforMED
MalfunctionCGL

EPOC READER

Received Jun 17, 2021 · Event occurred May 18, 2021

Report 3002637618-2021-00039 · MDR key 12017116

Device

Generic name

Epoc

Manufacturer

Epocal Inc.

Model number

HR-1002-00-00

Catalog number

10736398

Product problems

  • Non Reproducible Results
  • Non Reproducible Results

Patient

Not reported

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

Narrative

Additional Manufacturer Narrative

THE CUSTOMER HAS PROVIDED THE EXPECTED RESULTS HOWEVER NO COMPARATIVE TEST WERE RUN. THE CUSTOMER HAS PROVIDED INSTRUMENT FILES AND THE INVESTIGATION IS CURRENTLY UNDERWAY. THE CUSTOMER HAS STATED THAT THEY ARE CURRENTLY OPERATIONAL. THE CAUSE OF THIS EVENT IS UNKNOWN.

Description of Event or Problem

THE CUSTOMER ALLEGES DISCORDANT HCT TEST RESULTS WHEN USING THE EPOC READER SN (B)(4). THE CUSTOMER PERFORMED SEVEN READINGS OVER THE COURSE OF A PATIENT'S PROCEDURE, CARDIO PULMONARY BYPASS. THE CUSTOMER IS QUESTIONING RESULTS #3-7. THE CUSTOMER STATED THAT THE EXPECTED VALUE FOR RESULT #3 WAS 19-20%HCT AND THAT THE EXPECTED VALUE FOR RESULT #6 WAS 25-27%HCT. THERE WAS NO REPORT OF INJURY DUE TO THIS EVENT.

Additional Manufacturer Narrative

SIEMENS HAS COMPLETED THE INVESTIGATION: THE CAUSE OF THE HEMATOCRIT DISCREPANCY COULD NOT BE DETERMINED FROM THE INFORMATION PROVIDED BY THE CUSTOMER. THE CUSTOMER PROVIDED CSV FILES INCLUDING RESULTS FOR ANALYTES OTHER THAN HCT. THE CUSTOMER COULD ONLY PROVIDE RAW DATA FOR FAILED TESTS. WITHOUT RAW DATA (T_FILES) FOR THE ALLEGED DISCREPANT RESULTS, IT IS NOT POSSIBLE TO REACH A CONCLUSIVE CAUSE. A REVIEW OF THE IN-HOUSE PERFORMANCE FOR CARD LOT 10-21060-20 DID NOT IDENTIFY ANY PRODUCT DEFICIENCIES. THERE WAS NO INDICATION OF DISCREPANT RESULTS AT THE TIME OF PRODUCT RELEASE (FINISHED GOODS TESTING) NOR DURING LIFETIME STABILITY TESTING OR RETAIN LOT TESTING. IN ADDITION, THERE WERE NO OTHER COMPLAINTS RECEIVED ON CARD LOT 10-21060-20. THEREFORE, THERE IS NO EVIDENCE THAT THE SYSTEM OR REAGENT CARDS ARE NOT PERFORMING AS INTENDED. SAMPLE HANDLING (SUCH AS COLLECTION VESSEL, MIXING AND METHOD OF COLLECTION) ARE KNOWN TO AFFECT TEST RESULTS IF PROPER PRECAUTIONS ARE NOT CONSIDERED. THE CUSTOMER INDICATED THAT SEVERAL SAMPLES WERE OBTAINED DIRECTLY FROM THE BYPASS MACHINE. IT SHOULD BE NOTED THAT IMPROPER SAMPLE MIXING, INCLUDING SAMPLE COLLECTION FROM A SOURCE WITH A NON-UNIFORM CONCENTRATION CAN CONTRIBUTE TO VARIATION IN TEST RESULTS AND CANNOT BE RULED OUT AS A CONTRIBUTING FACTOR.