inforMED
MalfunctionLCP

TINA-QUANT HEMOGLOBIN A1CDX GEN. 3

Received Sep 25, 2023 · Event occurred Sep 1, 2023

Report 1823260-2023-03085 · MDR key 17808529

Device

Generic name

Glycosylated Hemoglobin Assay

Manufacturer

Roche Diagnostics

Catalog number

08056668190

Lot number

698253

Product problems

  • Incorrect, Inadequate or Imprecise Result or Readings
  • High Test Results
  • Non Reproducible Results
  • Incorrect, Inadequate or Imprecise Result or Readings
  • High Test Results
  • Non Reproducible Results

Patient

Unknown

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

Narrative

Additional Manufacturer Narrative

THE ALARM TRACE SHOWED FREQUENT ABNORMAL ASPIRATION ALARMS. THIS COULD INDICATE A CONTAMINATION OF THE PROBE. A PHOTO OF THE PROBE SHOWED CONTAMINATION. THE INVESTIGATION DETERMINED THE ACTION OF ADJUSTING THE WASH STATION RESOLVED THE ISSUE.

Additional Manufacturer Narrative

IT WAS OBSERVED THAT THE SAMPLE PROBE WAS COVERED IN GEL. THE MIXER ADJUSTMENT WAS CHECKED AND IT WAS OK. PROBES WERE CHANGED AND ADJUSTED. PRECISION STUDIES WERE PERFORMED BUT WERE NOT ACCEPTABLE. THE RINSE STATION WAS CLEANED AND IT WAS DETERMINED THAT IT NEEDED ADJUSTING. THE WASH STATION WAS ADJUSTED AND AFTER THIS, RECOVERY WAS ACCEPTABLE. THE INVESTIGATION IS ONGOING.

Description of Event or Problem

THE INITIAL REPORTER STATED THEY RECEIVED DISCREPANT RESULTS FOR THREE PATIENT SAMPLES TESTED WITH TINA-QUANT HEMOGLOBIN A1CDX GEN. 3 ON A COBAS PRO C 503 ANALYTICAL UNIT. THE FIRST SAMPLE INITIALLY RESULTED IN AN HBA1C RESULT OF 8.4 %. A SECOND SAMPLE COLLECTED FROM THE PATIENT RESULTED IN AN HBA1C VALUE OF 5.5 %. THE FIRST SAMPLE WAS THEN REPEATED ON (B)(6) 2023, RESULTING IN A VALUE OF 5.5 %. THE SECOND PATIENT SAMPLE INITIALLY RESULTED IN AN HBA1C VALUE OF 9.53 % AND IT REPEATED AS 7.34 %. THE THIRD PATIENT SAMPLE RESULTED IN THE FOLLOWING HBA1C VALUES ON (B)(6) 2023: 6.39 %, 9.36 %, 7.34 %, 8.19 %, 7.19 %, 6.95 %, 8.64 %, 12.5 %, 9.94 %, 12.2 %, AND 7.05 %.