inforMED
MalfunctionJIL

CHEMSTRIP 10 MD

Received Feb 20, 2023 · Event occurred Jan 23, 2023

Report 1823260-2023-00512 · MDR key 16404058

Device

Generic name

Urine Test Strips

Manufacturer

Roche Diagnostics

Model number

NA

Catalog number

03260763160

Lot number

64620501

Product problems

  • False Negative Result
  • False Negative Result

Patient

65 YR · Female

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

Narrative

Additional Manufacturer Narrative

THE METER AND TEST STRIPS WERE RECEIVED FOR INVESTIGATION. SECTIONS D9 AND H3 WERE UPDATED. THE TEST STRIPS SHOWED NO SIGNS OF DISCOLORATION. THE METER WAS DIRTY ON THE OUTSIDE. THE STRIP TRAY WAS SEVERELY CONTAMINATED DUE TO DIRT UNDER THE CLIP CAUSING A GAP, THEREFORE, THE TEST STRIP CAN'T BE PUSHED SUFFICIENTLY INTO THE TRAY. THE RETENTION MATERIAL OF LOT 64620500 AND THE CUSTOMER'S MATERIAL OF LOT 64620501 WAS CHECKED BY VISUAL READING WITH 0-NATIVE-URINE AND A LEUCOCYTES DILUTION. THE RETENTION MATERIAL OF LOT 64620500 AND THE CUSTOMER MATERIAL OF LOT 64620501 WAS MEASURED ON A URISYS 1100 AT THE INVESTIGATION SITE AND THE CUSTOMER'S URISYS 1100 WITH 0-NATIVE-URINE AND A LEUCOCYTES DILUTION. THE RESULTS OF ALL MEASUREMENTS FULFILL THE REQUIREMENTS. NO ABNORMAL RESULTS WERE OBSERVED. THE CONTAMINATED STRIP TRAY CAN CAUSE THE TEST STRIP TO BE POSITIONED INCORRECTLY AND LEAD TO INCORRECT RESULTS. PRODUCT LABELING STATES THE METER AND TEST STRIP TRAY SHOULD BE CLEANED DAILY: "MOISTEN A CLOTH WITH WATER, WRING IT OUT (THE CLOTH MUST BE DAMP NOT SOAKED) AND CLEAN THE EXTERIOR PARTS AND SURFACES OF THE INSTRUMENT." AND CAUTIONS "ENSURE THAT NO LIQUID ENTERS THE INSTRUMENT, WIPE THE HOUSING, AND NEVER SPRAY IT! LET THE HOUSING DRY BEFORE PROCEEDING TO READ." AND "PULL THE TEST STRIP TRAY OUT OF THE INSTRUMENT. RINSE THE TEST STRIP TRAY UNDER RUNNING WATER." AND CAUTIONS "ENSURE THAT THE POSITIONING HOLE ON THE SIDE OF THE TEST STRIP TRAY IS ABSOLUTELY DRY. THIS HOLE IS USED TO ENSURE THAT THE TEST STRIP TRAY IS AUTOMATICALLY POSITIONED CORRECTLY IN THE INSTRUMENT." THE TEST STRIP MUST BE PUSHED COMPLETELY UNDER THE CLIP WITHOUT A GAP TO ENSURE REPRODUCIBLE RESULTS. THE INVESTIGATION DID NOT IDENTIFY A PRODUCT PROBLEM.

Description of Event or Problem

THE INITIAL REPORTER QUESTIONED A RESULT FOR 1 PATIENT TESTED FOR LEUKOCYTES ON A URISYS 1100 URINE ANALYZER. THE REPORTER ALLEGED THE ANALYZER BEGAN TO COUNTDOWN AT 45 SECONDS INSTEAD OF 60 SECONDS. THE ANALYZER RESULT FROM A 45-SECOND COUNTDOWN WAS "NORMAL." THE CUSTOMER REPEATED THE TEST WITH A VISUAL CHECK DUE TO THE 45-SECOND COUNTDOWN ON THE METER INSTEAD OF A 60-SECOND COUNTDOWN. THE RESULT FROM THE VISUAL CHECK AT 60 SECONDS WAS 2+ (POSITIVE). THE POSITIVE VISUAL RESULT WAS BELIEVED TO BE CORRECT. THE URISYS 1100 ANALYZER SERIAL NUMBER WAS (B)(4).

Additional Manufacturer Narrative

THE METER AND TEST STRIPS WERE REQUESTED FOR INVESTIGATION. THE INVESTIGATION STATED THE REASON THE ANALYZER COUNTED DOWN FROM 45 SECONDS INSTEAD OF 60 SECONDS WAS THAT THE COUNTDOWN INCLUDES THE TOTAL TIME FROM WHEN THE TEST STRIP IS REMOVED FROM THE VIAL. AFTER DIPPING, BLOTTING, AND INSERTING THE TEST STRIP, APPROXIMATELY 15 SECONDS ELAPSED AND THEN THE 45-SECOND COUNTDOWN BEGINS WHEN THE START BUTTON IS PRESSED. PRODUCT LABELING STATES: "IT IS IMPORTANT THAT THE STRIP IS CORRECTLY POSITIONED AND READY TO BE READ WITHIN 5-10 SECONDS OF DIPPING STRIP." THE INVESTIGATION IS ONGOING.