STATSTRIP GLUCOSE HOSPITAL METER
Received Nov 11, 2021 · Event occurred Oct 31, 2021
Report 1219029-2021-00050 · MDR key 12796602
Device
Product problems
- Patient Data Problem
- Patient Data Problem
Patient
Unknown
- No Clinical Signs, Symptoms or Conditions
- No Clinical Signs, Symptoms or Conditions
Narrative
Additional Manufacturer Narrative
(B)(4). THE CUSTOMER IS LOCATED IN (B)(6) WHERE THE METER PART NUMBER IS 54794. AS THE MANUFACTURER, A SIMILAR DEVICE PART NUMBER FOR THE US TO REPORT IS 54790. THEREFORE, THE REPORT IS BEING SUBMITTED TO THE FDA UNDER 54790 AND THE SUBSEQUENT REPORT TO (B)(6) WILL REFLECT 54794. THE FACILITY REPORTED PATIENT BARCODE SCAN ERROR ON A PATIENT'S IDENTIFICATION NUMBER. THEY DID NOT REPORT ANY PATIENT HARM OR MEDICAL INTERVENTION. THE FACILITY IS CONTINUING TO UTILIZE THE METER, THEREFORE; NO SAMPLE WAS RETURNED TO NOVA FOR EVALUATION. A DEVICE HISTORY RECORD (DHR) REVIEW FOR THE METER WAS PERFORMED. THE REVIEW INCLUDED AN ASSESSMENT OF THE PRODUCTION, TESTING, AND RELEASE OF THE PRODUCTS. NO ABNORMALITIES OR CONCERNS WERE OBSERVED; THE DHR INDICATED THE RELEASED PRODUCT MET ALL SPECIFICATIONS. PREVIOUSLY OPENED AND INVESTIGATED INCIDENTS FROM THE CUSTOMER FACILITY DETERMINED THE ROOT CAUSE FOR THE PATIENT MISREADS IS ATTRIBUTED TO THE USER FACILITY USING POOR QUALITY 1D BARCODES THAT WERE PRINTED USING CODE -39 SYMBOLOGY. CODE-39 IS NO LONGER INDUSTRY STANDARD AND HAS A HIGHER SUBSTITUTION FAILURE RATE THAN CODE-128 AND MUCH HIGHER THAN THE STANDARD 2D BARCODES AVAILABLE. THIS FAILURE MODE DOES NOT REPRESENT A SYSTEMIC ISSUE OR A FAILURE OF THE METER TO PERFORM AS INTENDED. THE FAILURE MODE IS DIRECTLY RELATED TO THE QUALITY OF THE BARCODE BEING GENERATED BY THE CUSTOMER. THE ROOT CAUSE OF THE MISREAD IS MOST LIKELY DUE TO POOR BARCODE QUALITY. BASED ON THE ORIGINAL INVESTIGATION, NOVA SUGGESTED TO PREVENT BARCODE MIS-READS IN THE FUTURE, THE CUSTOMER SHOULD CHANGE FROM A 1D TO A 2D BARCODE, WHICH WOULD GREATLY REDUCE THE CHANCES OF A BARCODE MISREAD. TRENDING WILL BE MONITORED FOR THIS AND OR SIMILAR COMPLAINTS.
Description of Event or Problem
THE CUSTOMER REPORTED THAT THERE WAS A BAR CODE SCANNING ERROR ON A PATIENT'S IDENTIFICATION NUMBER WHILE USING A STAT STRIP (1.86) METER. THE INCIDENT OCCURRED ON (B)(6) 2021. THE CUSTOMER STATED THAT THEY WERE UNAWARE OF ANY POTENTIAL PATIENT HARM FROM THE BARCODE MISREAD AND WILL NOT BE RETURNING THE METER AS IT IS CURRENTLY IN USE AT THE FACILITY.