inforMED
MalfunctionCIX

CLIN CHEM ALBUMIN BCG REAGENT

Received Feb 15, 2011 · Event occurred Jan 29, 2010

Report 2018433-2011-00001 · MDR key 1991224

Device

Generic name

Quantitation Of Albumin In Human Serum Or Plasma

Catalog number

7D53-21

Product problems

  • Calibration Error
  • Nonstandard Device
  • Incorrect Or Inadequate Test Results
  • Improper Device Output

Patient

Not reported

  • No Known Impact Or Consequence To Patient

Narrative

Additional Manufacturer Narrative

(B)(4). CONCOMITANT MEDICAL PRODUCTS: ARCHITECT ANALYZER, LIST #1G06-01, (B)(4). THE CAUSE OF THE PARTICULATE MATTER ((B)(4), A FUNGAL SPECIES FOUND IN THE ENVIRONMENT) OBSERVED IN SOME CLINICAL CHEMISTRY (B)(4) REAGENT CARTRIDGES WAS DUE TO EXPOSURE OF THE ALBUMIN BCG FORMULA CONTAINING WEAK ANTIMICROBIAL ADDITIVE FROM NORMAL FORMULATION AND FILTERING PROCESSES DESIGNED FOR MICROBIAL GROWTH CONTROLLED CLINICAL CHEMISTRY REAGENTS. ABBOTT ISSUED A PRODUCT RECALL ADVISING CUSTOMERS TO DISCARD OR DESTROY ANY INVENTORY OF THREE AFFECTED LOTS OF CLINICAL CHEMISTRY ALBUMIN BCG REAGENTS. ABBOTT IS IDENTIFYING ALTERNATE FORMULATION FOR THE CLINICAL CHEMISTRY ALBUMIN REAGENTS THAT CONTAIN NO MERCURY.

Description of Event or Problem

THE CUSTOMER OBSERVED CLINICAL CHEMISTRY ALBUMIN BCG CONTROLS OUT OF RANGE WHEN REVIEWING THE NIGHT SHIFT'S QUALITY CONTROL DATA. THE CUSTOMER DETERMINED PATIENT RESULTS WERE REPORTED OUT OF THE LAB WHEN THE ALBUMIN CONTROLS WERE OUT OF RANGE. THE CUSTOMER SENT CALIBRATION DATA, LEVY-JENNINGS DATA AND PATIENT DATA TO ABBOTT FOR EVALUATION. THE CUSTOMER SUCCESSFULLY RECALIBRATED THE ALBUMIN ASSAY WITH THE QUALITY CONTROLS WITHIN SPECIFICATION AND RE-ASSAYED PATIENT SAMPLES FROM THE RUN WITH CONTROLS OUT OF RANGE. AN EXAMPLE OF THE PATIENT DATA IS AS FOLLOWS: INITIAL RESULT: 3.1 G/DL, REPEAT RESULT: 4.3 G/DL THE INITIAL PATIENT RESULT AND A CORRECTED PATIENT RESULT WAS REPORTED OUT OF THE LAB, HOWEVER, THERE WAS NO IMPACT TO PATIENT MANAGEMENT.

Remedial action

  • Recall