inforMED
MalfunctionCFJ

LACTATE DEHYDROGENASE

Received Mar 26, 2024 · Event occurred Mar 6, 2024

Report 1823260-2024-00911 · MDR key 18979865

Device

Generic name

Lactate Dehydrogenase Assay Using Nad/nadh

Manufacturer

Roche Diagnostics

Catalog number

03004732122

Lot number

72604101

Product problems

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

Patient

15 YR · Female

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

Narrative

Additional Manufacturer Narrative

THE FIELD APPLICATION SPECIALIST PERFORMED CALIBRATION AND REPEATED THE PATIENT COMPARISONS USING REAGENT LOTS 747707 AND 773098. THE COMPARISON WAS ACCEPTABLE. THE ANALYZER ALARM TRACE CONTAINED MULTIPLE ALARMS INDICATING ISSUES WITH SAMPLE QUALITY. THE INVESTIGATION DID NOT IDENTIFY A PRODUCT PROBLEM. THE SPECIFIC CAUSE OF THE EVENT COULD NOT BE DETERMINED.

Description of Event or Problem

THERE WAS AN ALLEGATION OF QUESTIONABLE LACTATE DEHYDROGENATE (LDHI GEN.2) RESULTS FROM THE COBAS 6000 C 501 ANALYZER. THE CUSTOMER WAS SWITCHING TO A NEW LOT OF REAGENT AND PERFORMED A PATIENT COMPARISON. THE SAMPLES WERE REPEATED ON ANOTHER COBAS 6000 C 501 USING NEW REAGENT LOT 747707. THE CUSTOMER DID NOT KNOW WHICH RESULT WAS CORRECT. PATIENT 1 INITIAL RESULT WAS 377 U/L AND THE REPEAT RESULT WAS 245 U/L. PATIENT 2 INITIAL RESULT WAS 260 U/L AND THE REPEAT RESULT WAS 153 U/L. PATIENT 3 INITIAL RESULT WAS 390 U/L AND THE REPEAT RESULT WAS 245 U/L. PATIENT 4 INITIAL RESULT WAS 262 U/L AND THE REPEAT RESULT WAS 153 U/L.

Additional Manufacturer Narrative

THE COBAS 6000 C 501 ANALYZER SERIAL NUMBER WAS (B)(6). THE INVESTIGATION IS ONGOING.