inforMED
MalfunctionCEO

PHOSPHATE (INORGANIC) VER.2

Received Jul 12, 2022 · Event occurred Jun 19, 2022

Report 1823260-2022-02049 · MDR key 14984854

Device

Generic name

Phosphomolybdate (colorimetric) - Inorganic Phosphorous

Manufacturer

Roche Diagnostics

Model number

PHOS2

Catalog number

08058610190

Lot number

57951801

Product problems

  • Low Test Results
  • Low Test Results

Patient

46 YR · Female

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

Narrative

Additional Manufacturer Narrative

NA.

Description of Event or Problem

THE INITIAL REPORTER STATED THEY RECEIVED DISCREPANT RESULTS FOR ONE PATIENT SAMPLE TESTED WITH PHOS2 PHOSPHATE (INORGANIC) VER.2 ON A COBAS C 503 ANALYTICAL UNIT (SERIAL NUMBER (B)(4)). NO INCORRECT RESULTS WERE REPORTED OUTSIDE OF THE LABORATORY. THE SAMPLE INITIALLY RESULTED IN A PHOSPHORUS VALUE OF 2.69 MG/DL ACCOMPANIED BY A DATA FLAG INDICATING ATYPICAL KINETIC BEHAVIOR. THE SAMPLE WAS REPEATED, RESULTING IN A PHOSPHORUS VALUE OF 2.68 MG/DL ACCOMPANIED BY A DATA FLAG INDICATING ATYPICAL KINETIC BEHAVIOR. THE SAMPLE WAS DILUTED 1:3 AND REPEATED, RESULTING IN A PHOSPHORUS VALUE OF 2.33 MG/DL ACCOMPANIED BY A DATA FLAG. THE SAMPLE WAS REPEATED AGAIN AT DECREASED SAMPLE VOLUME, RESULTING IN A PHOSPHORUS VALUE OF 2.55 MG/DL ACCOMPANIED BY A DATA FLAG INDICATING ATYPICAL KINETIC BEHAVIOR. THE SAMPLE WAS THEN REPEATED ON A SECOND ANALYZER AT DECREASED SAMPLE VOLUME, RESULTING IN A PHOSPHORUS VALUE OF 3.54 MG/DL. THIS VALUE WAS DEEMED CORRECT.

Additional Manufacturer Narrative

THE CUSTOMER STATED THE PATIENT SAMPLE WAS ICTERIC UPON VISUAL CHECK. THE ISSUE WAS RESOLVED BY RE-DRAWING THE PATIENT. THE INVESTIGATION DETERMINED THE CUSTOMER ACTIONS RESOLVED THE ISSUE.