inforMED
MalfunctionCDX

ELECSYS T4

Received Nov 29, 2023 · Event occurred Nov 6, 2023

Report 1823260-2023-03794 · MDR key 18232768

Device

Generic name

Total Thyroxine Assay

Manufacturer

Roche Diagnostics

Catalog number

ASKU

Lot number

ASKU

Product problems

  • Incorrect Measurement
  • High Test Results
  • Incorrect Measurement
  • High Test Results

Patient

53 YR · Female

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

Narrative

Additional Manufacturer Narrative

INVESTIGATIONS OF THE SAMPLE WERE ABLE TO REPRODUCE THE RESULTS OBTAINED BY THE CUSTOMER. FURTHER INVESTIGATIONS OF THE SAMPLE DETERMINED THAT IT CONTAINS AN INTERFERING FACTOR AGAINST THE STREPTAVIDIN COMPONENT OF THE T3 AND T4 ASSAYS. PER PRODUCT LABELING: "IN RARE CASES, INTERFERENCE DUE TO EXTREMELY HIGH TITERS OF ANTIBODIES TO ANALYTE-SPECIFIC ANTIBODIES, STREPTAVIDIN, OR RUTHENIUM CAN OCCUR. THESE EFFECTS ARE MINIMIZED BY SUITABLE TEST DESIGN." THE INVESTIGATION DID NOT IDENTIFY A PRODUCT ISSUE.

Additional Manufacturer Narrative

THE SERIAL NUMBER OF THE E 801 ANALYZER IS (B)(6). THE FULL E1 FACILITY NAME WAS PROVIDED AS "SICHUAN PROVINCIAL PEOPLE'S HOSPITAL SICHUAN PROVINCIAL PEOPLE'S HOSPITAL". THE PATIENT SAMPLE WAS PROVIDED FOR INVESTIGATION. THE INVESTIGATION IS ONGOING.

Description of Event or Problem

THE INITIAL REPORTER STATED THEY RECEIVED QUESTIONABLE RESULTS FOR ONE PATIENT SAMPLE TESTED WITH ELECSYS T3 AND ELECSYS T4 ON A COBAS E 801 ANALYTICAL UNIT. THE CUSTOMER STATES THAT THE T3 AND T4 VALUES WERE ABNORMALLY ELEVATED, BUT TSH WAS NORMAL. THE RESULTS WERE NOT IN LINE WITH THE PATIENT'S CLINICAL MANIFESTATIONS. NO QUESTIONABLE RESULTS WERE REPORTED OUTSIDE OF THE LABORATORY. THIS MEDWATCH WILL APPLY TO THE T4 ASSAY. PLEASE REFER TO THE MEDWATCH WITH A1. PATIENT IDENTIFIER (B)(6) FOR INFORMATION RELATED TO THE T3 ASSAY. REFER TO THE ATTACHMENT FOR THE PATIENT'S RESULTS. THE T3 AND T4 VALUES FROM THE 06-NOV-2023 SAMPLE ARE QUESTIONED. THE SAMPLE WAS REPEATED AFTER THE PATIENT SAMPLE WAS TREATED WITH THE STREPTAVIDIN-COATED MICROPARTICLE PORTION OF THE T3 AND T4 REAGENTS. FOR THIS TREATMENT, THE SAMPLE AND MICROPARTICLE PORTION OF THE REAGENTS WERE INCUBATED AT 37 DEGREES CELCIUS FOR 30 MINUTES, THE SUPERNATANT WAS THEN CENTRIFUGED AND TESTED.