inforMED
MalfunctionCGR

DSL-10-2000 ACTIVE® CORTISOL ENZYME IMMUNOASSAY (EIA) KIT

Received Jul 21, 2009 · Event occurred Jul 9, 2009

Report 1628193-2009-00001 · MDR key 1416817

Device

Generic name

Active® Cortisol Eia, 96 Wells

Model number

NA

Catalog number

DSL-10-2000

Product problems

  • High Test Results

Patient

Not reported

  • No Patient Involvement

Narrative

Description of Event or Problem

DURING AN INTERNAL TESTING CONDUCTED BY BECKMAN COULTER INC. (BCI), IT WAS REPORTED THAT FALSE HIGH CORTISOL VALUES WERE GENERATED BY THE DSL-10-2000 ACTIVE CORTISOL ENZYME IMMUNOASSAY (EIA) KIT. BECKMAN COULTER HAS CONFIRMED THAT THE FOLLOWING LOT NUMBERS: 04195, 04195A, 04195B, 04195D, 04195E, 04195F, 09266A, 09266, 04126A, 04126, 03066A, 03066, 01036, 716217, 716218, 800408, 800409, 800410, 890929 AND 990168 OF ACTIVE CORTISOL ELISA CALIBRATORS OVER ESTIMATE THE EXPECTED DOSE VALUES FOR PATIENT SERUM SAMPLES DUE TO A SHIFT IN THE ASSIGNED CALIBRATOR VALUES. AN EXAMPLE FOR LOT 990168 WHICH YIELDED VALUES SIGNIFICANTLY ABOVE (2-5X) OTHER PRODUCTS. ALL KITS WITH AFFECTED LOTS RESULTED IN OVERESTIMATION OF CORTISOL DOSE. PATIENT RESULTS WERE NOT GENERATED IN THIS EVENT SINCE THE EVENT WAS DISCOVERED IN-HOUSE AND NO PATIENT SAMPLES WERE TESTED AT THE TIME. THERE WAS NO AFFECT TO PATIENT TREATMENT AS A RESULT OF THIS EVENT.

Additional Manufacturer Narrative

ROOT CAUSE OF THE SHIFT IN THE CALIBRATION OF THE ASSIGNED STANDARD VALUES IS CURRENTLY UNDER INVESTIGATION. A MALFUNCTION WILL BE ASSUMED FOR THE PURPOSE OF THIS REPORT.