inforMED
MalfunctionPRI

ELECSYS BRAHMS PCT

Received Feb 28, 2023 · Event occurred Feb 2, 2023

Report 1823260-2023-00617 · MDR key 16454548

Device

Generic name

Procalcitonin Assay

Manufacturer

Roche Diagnostics

Model number

NA

Catalog number

08828679190

Lot number

59498801

Product problems

  • Low Test Results
  • Non Reproducible Results
  • Low Test Results
  • Non Reproducible Results

Patient

Unknown

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

Narrative

Description of Event or Problem

THE INITIAL REPORTER STATED THEY RECEIVED DISCREPANT RESULTS FOR ONE PATIENT SAMPLE TESTED WITH THE ELECSYS BRAHMS PCT ASSAY ON A COBAS E 801 ANALYTICAL UNIT. THE SAMPLE INITIALLY RESULTED IN A PCT VALUE OF 0.16 NG/ML. THE RESULT WAS REPORTED OUTSIDE OF THE LABORATORY AND QUESTIONED. THE SAMPLE WAS REPEATED RESULTING IN A PCT VALUE OF 28.9 NG/ML. A NEW SAMPLE DRAW OF THE PATIENT RESULTED IN A PCT VALUE OF 27.3 NG/ML.

Additional Manufacturer Narrative

THE LAST CALIBRATION PERFORMED ON (B)(6) 2023, AND THE QUALITY CONTROLS RESULTS DO NOT INDICATE A GENERAL REAGENT ISSUE. UPON REVIEW OF THE ALARM TRACE, NO GENERAL INSTRUMENT ISSUE WAS DETECTED. IT WAS DETERMINED THAT THE TIP OF THE SAMPLE PROBE HAD A CRYSTAL, INDICATING INADEQUATE DAILY SAMPLE PROBE MANUAL CLEANING BY THE OPERATOR. THE CRYSTALS COULD BE CONTAMINATING THE ASPIRATED SAMPLE BUT WOULD NOT CAUSE THE OBSERVED EVENT. THE INVESTIGATION COULD NOT IDENTIFY A PRODUCT PROBLEM. THE CAUSE OF THE EVENT COULD NOT BE DETERMINED.