inforMED
MalfunctionJGS

NA ELECTRODE

Received May 23, 2024 · Event occurred May 4, 2024

Report 1823260-2024-01537 · MDR key 19381041

Device

Generic name

Electrode, Ion Specific, Sodium

Manufacturer

Roche Diagnostics

Catalog number

10825468001

Lot number

V58

Product problems

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

Patient

NA · Unknown

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

Narrative

Description of Event or Problem

THERE WAS AN ALLEGATION OF QUESTIONABLE SODIUM RESULTS FROM THE COBAS PRO ISE ANALYTICAL UNIT. SAMPLE 111761155 INITIAL RESULT WAS 149 MMOL/L AND THE REPEAT RESULT WAS 140 MMOL/L. SAMPLE 111761293 INITIAL RESULT WAS 140 MMOL/L AND THE REPEAT RESULT WAS 134 MMOL/L. SAMPLE 111761354 INITIAL RESULT WAS 138 MMOL/L AND THE REPEAT RESULT WAS 132 MMOL/L.

Additional Manufacturer Narrative

THE COBAS PRO ISE ANALYTICAL UNIT SERIAL NUMBER WAS(B)(6) . THE CUSTOMER PERFORMED QUARTERLY MAINTENANCE AND HAS NOT HAD ANY FURTHER ISSUES. THE INVESTIGATION IS ONGOING.

Additional Manufacturer Narrative

THE FIELD SERVICE ENGINEER FOUND THE FLUIDIC PATHWAYS WERE COMPROMISED. HE REQUESTED THE CUSTOMER TO COMPLETE MONTHLY MAINTENANCE. A PRECISION CHECK WAS PERFORMED WITH PASSING RESULTS. AS THE QC RECOVERY WAS ACCEPTABLE THERE WAS NO INDICATION OF A PERFORMANCE ISSUE OF REAGENT. THE ANALYZER ALARM TRACE CONTAINED SAMPLE PROBE, SAMPLE SHORT, AND SAMPLE PROBE ABNORMAL ASPIRATION ALARMS. THIS IS AN INDICATION OF POSSIBLE POOR SAMPLE QUALITY. THE INVESTIGATION DETERMINED THE SERVICE AND CUSTOMER ACTIONS RESOLVED THE ISSUE.