DIMENSION®
Received Jun 2, 2023 · Event occurred May 10, 2023
Report 2432235-2023-00132 · MDR key 17049053
Device
Generic name
Dimension® Cyclosporine Flex® Reagent Cartridge
Manufacturer
Siemens Healthcare Diagnostics Inc.Model number
10285193Catalog number
DF89A SMN 10285193
Lot number
FA3287
Product problems
- High Test Results
- High Test Results
Patient
Unknown
- No Clinical Signs, Symptoms or Conditions
- No Clinical Signs, Symptoms or Conditions
Narrative
Additional Manufacturer Narrative
ADDITIONAL INFORMATION (09-JUN-2023): SIEMENS HEALTHCARE DIAGNOSTICS HEADQUARTERS SUPPORT CENTER (HSC) AND TECHNICAL OPERATIONS (TECHOPS) CONCLUDED THE INVESTIGATION OF THE EVENT. HSC REVIEWED THE ATTACHMENT (PHOTO) AND THE INFORMATION PROVIDED BY THE CUSTOMER. THE ATTACHMENT SHOWED THAT THE CHROMIUM OXIDE (CRO2) TABLET WAS ATTACHED TO THE TOP OF THE FLEX FILM AND DID NOT HYDRATE. THE TABLET BEING ATTACHED TO THE TOP OF FLEX FILM COULD PREVENT THE REACTION FROM COMPLETING. SIEMENS HEALTHCARE DIAGNOSTICS TECHOPS REVIEWED THE INFORMATION PROVIDED AND CONCLUDED THAT A PRODUCT NON-CONFORMANCE WAS NOT IDENTIFIED WITH THE CSA ASSAY OR THE DIMENSION EXL 200 SYSTEM. THE EVENT IS CONSISTENT WITH A TABLET HYDRATION ISSUE. THE CAUSE OF THE EVENT IS UNKNOWN. A POTENTIAL PRODUCT ISSUE WAS NOT IDENTIFIED. THE CUSTOMER IS OPERATIONAL. THE DEVICE IS PERFORMING WITHIN SPECIFICATIONS. NO FURTHER EVALUATION IS REQUIRED. SECTION H6 HAS BEEN UPDATED TO REFLECT THE SIEMENS INVESTIGATION. INITIAL MDR 2432235-2023-00132 WAS FILED ON 02-JUN-2023.
Description of Event or Problem
TWO (2) DISCORDANT FALSELY ELEVATED CYCLOSPORINE A (CSA) RESULTS WERE OBTAINED ON A PATIENT SAMPLE ON A DIMENSION EXL 200 SYSTEM. ONE OF THE FALSELY ELEVATED RESULTS WAS REPORTED TO THE PHYSICIAN(S), AND THE RESULT WAS QUESTIONED. THE SAME SAMPLE WAS REPROCESSED ON AN ALTERNATE DIMENSION EXL 200 SYSTEM, AND THE REPROCESSED RESULT WAS CONSIDERED CORRECT. A CORRECTED REPORT WAS ISSUED. THERE ARE NO KNOWN REPORTS OF PATIENT INTERVENTION OR ADVERSE HEALTH CONSEQUENCES DUE TO THE FALSELY ELEVATED CYCLOSPORINE A (CSA) RESULTS.
Additional Manufacturer Narrative
AN OUTSIDE OF THE UNITED STATES (OUS) CUSTOMER CONTACTED THE SIEMENS HEALTHCARE DIAGNOSTICS REMOTE SERVICES CENTER (RSC) REGARDING TWO (2) FALSELY ELEVATED CYCLOSPORINE A (CSA) PATIENT SAMPLE RESULTS OBTAINED ON A DIMENSION EXL 200 SYSTEM. SIEMENS IS INVESTIGATING THE EVENT.