inforMED
MalfunctionCDD

ELECSYS VITAMIN B12 II

Received Jul 25, 2024 · Event occurred Jul 2, 2024

Report 1823260-2024-02166 · MDR key 19829673

Device

Generic name

Radioassay, Vitamin B12

Manufacturer

Roche Diagnostics

Catalog number

07212771190

Lot number

76500602

Product problems

  • Low Test Results
  • Low Test Results

Patient

65 YR · Female

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

Narrative

Description of Event or Problem

THERE WAS AN ALLEGATION OF QUESTIONABLE ELECSYS VITAMIN B12 IMMUNOASSAY RESULTS FOR 1 PATIENT SAMPLE ON A COBAS E 411 IMMUNOASSAY ANALYZER. THE INITIAL B12 RESULT WAS 126.4 PG/ML. THE SAMPLE WAS REPEATED TWICE AND THE RESULTS WERE APPROXIMATELY 155 PG/ML AND 165 PG/ML. AN ALIQUOT OF THE SAMPLE WAS ALSO SENT TO ANOTHER LABORATORY WHERE IT WAS TESTED ON A SIEMENS ANALYZER AND THE B12 RESULT WAS 224 PG/ML.

Additional Manufacturer Narrative

THE ANALYZER SERIAL NUMBER IS (B)(6). THE INVESTIGATION IS ONGOING.

Additional Manufacturer Narrative

IT WAS FOUND THAT THE CUSTOMER ONLY CENTRIFUGES PATIENT SAMPLES FOR 5 MINUTES, WHICH IS TOO SHORT. THE QC RECOVERY DATA PROVIDED WAS ACCEPTABLE. THE FIELD SERVICE ENGINEER (FSE) PERFORMED PERIODIC MAINTENANCE ON THE ANALYZER. THE INVESTIGATION DID NOT IDENTIFY A PRODUCT PROBLEM. THE ROOT CAUSE OF THE EVENT COULD NOT BE DETERMINED.