inforMED
MalfunctionOIU

ELECSYS HE4 ASSAY

Received Jan 18, 2022 · Event occurred Dec 24, 2021

Report 1823260-2022-00140 · MDR key 13284875

Device

Generic name

Epithelial Ovarian Tumor Associated Antigen (he4) Test

Manufacturer

Roche Diagnostics

Model number

NA

Catalog number

05950929190

Lot number

533180

Product problems

  • Low Test Results
  • Low Readings
  • Low Test Results
  • Low Readings

Patient

Unknown

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

Narrative

Description of Event or Problem

THE INITIAL REPORTER COMPLAINED OF DISCREPANT RESULTS FOR 8 PATIENT SAMPLES TESTED FOR ELECSYS HE4 ASSAY (HE4) ON A COBAS 8000 E 602 MODULE. THE QUESTIONABLE RESULTS WERE FROM ONE PARTICULAR REAGENT PACK. THE REPEAT RESULTS WERE FROM THE SAME LOT NUMBER BUT A DIFFERENT REAGENT PACK. REFER TO ATTACHED DATA FOR THE RESULTS. THE QUESTIONABLE RESULTS WERE REPORTED OUTSIDE OF THE LABORATORY. THE E602 MODULE SERIAL NUMBER WAS (B)(4).

Additional Manufacturer Narrative

THE INITIAL QC RESULTS WERE OUTSIDE OF THE TARGET RANGE; THE REPEAT QC RESULTS WERE WITHIN THE TARGET RANGE. MICROBEADS WERE FOUND AGGLUTINATED ON THE LID OF THE REAGENT PACK IN QUESTION. THE ISSUE WAS RESOLVED WHEN THE CUSTOMER CHANGED TO A DIFFERENT REAGENT PACK. A GENERAL REAGENT ISSUE CAN BE EXCLUDED AS THE REPEAT RESULTS FROM A DIFFERENT REAGENT PACK WITH THE SAME LOT NUMBER GAVE EXPECTED RESULTS. THE INVESTIGATION DID NOT IDENTIFY A PRODUCT PROBLEM. THE INVESTIGATION DETERMINED THE EVENT WAS CONSISTENT WITH A TRANSPORTATION OR STORAGE ISSUE AFFECTING ONE PARTICULAR REAGENT PACK.

Additional Manufacturer Narrative

THE INITIAL QC RESULTS WERE OUTSIDE OF THE TARGET RANGE; THE REPEAT QC RESULTS WERE WITHIN THE TARGET RANGE. MICROBEADS WERE FOUND AGGLUTINATED ON THE LID OF THE REAGENT PACK IN QUESTION. THE ISSUE WAS RESOLVED WHEN THE CUSTOMER CHANGED TO A DIFFERENT REAGENT PACK. A GENERAL REAGENT ISSUE CAN BE EXCLUDED AS THE REPEAT RESULTS FROM A DIFFERENT REAGENT PACK WITH THE SAME LOT NUMBER GAVE EXPECTED RESULTS. THE INVESTIGATION DID NOT IDENTIFY A PRODUCT PROBLEM. THE INVESTIGATION DETERMINED THE EVENT WAS CONSISTENT WITH A TRANSPORTATION OR STORAGE ISSUE AFFECTING ONE PARTICULAR REAGENT PACK.

Description of Event or Problem

THE INITIAL REPORTER COMPLAINED OF DISCREPANT RESULTS FOR 8 PATIENT SAMPLES TESTED FOR ELECSYS HE4 ASSAY (HE4) ON A COBAS 8000 E 602 MODULE. THE QUESTIONABLE RESULTS WERE FROM ONE PARTICULAR REAGENT PACK. THE REPEAT RESULTS WERE FROM THE SAME LOT NUMBER BUT A DIFFERENT REAGENT PACK. REFER TO ATTACHED DATA FOR THE RESULTS. THE QUESTIONABLE RESULTS WERE REPORTED OUTSIDE OF THE LABORATORY. THE E602 MODULE SERIAL NUMBER WAS (B)(4).