inforMED
MalfunctionCDD

ELECSYS VITAMIN B12 II

Received Jul 12, 2023 · Event occurred May 31, 2023

Report 1823260-2023-02224 · MDR key 17308901

Device

Generic name

Radioassay, Vitamin B12

Manufacturer

Roche Diagnostics

Model number

B12 G2

Catalog number

07212771190

Lot number

70733100

Product problems

  • Imprecision
  • Low Test Results
  • Non Reproducible Results
  • Imprecision
  • 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 ELECSYS VITAMIN B12 II ON A COBAS E411 DISK. NO QUESTIONABLE RESULTS WERE REPORTED OUTSIDE OF THE LABORATORY. THE CUSTOMER LOADED A NEW VITAMIN B12 REAGENT PACK ON THE INSTRUMENT AND PERFORMED A CALIBRATION. THE CONTROL RECOVERED 2 STANDARD DEVIATIONS LOWER THAN THE MEAN. THE PATIENT SAMPLE WAS THEN INITIALLY TESTED AND RESULTED IN A VITAMIN B12 VALUE OF 178.5 PG/ML. THE CUSTOMER THEN RE-CALIBRATED THE VITAMIN B12 REAGENT WITH NEW CALIBRATOR MATERIAL AND THE CONTROL RECOVERED 2 STANDARD DEVIATIONS ABOVE THE MEAN. THE PATIENT SAMPLE WAS THEN REPEATED, RESULTING IN A VITAMIN B12 VALUE OF 328.1 PG/ML.

Additional Manufacturer Narrative

THE SERIAL NUMBER OF THE E411 ANALYZER IS (B)(6). THE INVESTIGATION IS ONGOING. H3 OTHER TEXT : NA.

Additional Manufacturer Narrative

THE INVESTIGATION WAS UNABLE TO DETERMINE A SPECIFIC ROOT CAUSE. AS THE ISSUE IMPROVED AFTER A NEW CALIBRATOR ALIQUOT WAS USED, THE ISSUE IS CONSISTENT WITH CALIBRATOR HANDLING AND/OR STORAGE ISSUES. NO GENERAL REAGENT ISSUE WAS FOUND.