inforMED
MalfunctionCGA

VITROS XT CHEMISTRY PRODUCTS GLU-CA SLIDES

Received Sep 12, 2024 · Event occurred Aug 16, 2024

Report 1319809-2024-00071 · MDR key 20201668

Device

Generic name

In-vitro Diagnostics

Catalog number

6844295

Lot number

7419-0016-8376

Product problems

  • Low Test Results
  • Low Test Results

Patient

NA · Unknown

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

Narrative

Additional Manufacturer Narrative

THE INVESTIGATION DETERMINED THAT A NON-REPRODUCIBLE, LOWER THAN EXPECTED RESULT WAS OBTAINED FROM A SINGLE PATIENT SAMPLE USING VITROS GLUCOSE (GLUXT) SLIDE LOT 7419-0016-8376 TESTED ON A VITROS XT 7600 INTEGRATED SYSTEM. THE MOST LIKELY ASSIGNABLE CAUSE FOR THIS EVENT COULD NOT BE DETERMINED. BASED ON HISTORIC QUALITY CONTROL RESULTS, THERE WAS SOME IMPRECISION OBSERVED USING VITROS GLUXT SLIDE LOT 7419-0016-8376, HOWEVER, THE MAGNITUDE OF BIAS OBSERVED WOULD NOT HAVE CONTRIBUTED TO THE BIAS OBSERVED WITH THE AFFECTED PATIENT SAMPLE. THEREFORE, VITROS GLUXT SLIDE LOT 7419-0016-8376 DID NOT LIKELY CONTRIBUTE TO THE EVENT. CONTINUAL TRACKING AND TRENDING OF COMPLAINTS HAS NOT IDENTIFIED ANY SIGNALS THAT WOULD POINT TO A POTENTIAL SYSTEMIC ISSUE WITH VITROS GLUXT SLIDE LOT 7419-0016-8376. BASED ON ACCEPTABLE DIAGNOSTIC VITROS ALKP WITHIN-RUN PRECISION TESTING, THE VITROS XT 7600 INTEGRATED SYSTEM WAS PERFORMING AS INTENDED AND DID NOT LIKELY CONTRIBUTE TO THE EVENT. FINALLY, IMPROPER PRE-ANALYTICAL SAMPLE PROCESSING CANNOT BE RULED OUT AS CONTRIBUTING TO THE EVENT. IT IS UNKNOWN IF THE AFFECTED SAMPLE WAS CENTRIFUGED ACCORDING TO THE SAMPLE COLLECTION DEVICE MANUFACTURER'S SPECIFICATIONS, AND IT IS POSSIBLE THAT CELLULAR DEBRIS, DUE TO POOR SAMPLE PREPARATION, WAS PRESENT IN THE AFFECTED SAMPLES, ALTHOUGH THIS COULD NOT BE CONFIRMED.

Description of Event or Problem

A CUSTOMER CONTACTED THE ORTHO CLINICAL DIAGNOSTICS (ORTHO) TECHNICAL SOLUTION CENTER (TSC) TO REPORT A NON-REPRODUCIBLE, LOWER THAN EXPECTED RESULT WAS OBTAINED FROM A SINGLE PATIENT SAMPLE USING VITROS GLUCOSE (GLUXT) SLIDE LOT 7419-0016-8376 TESTED ON A VITROS XT 7600 INTEGRATED SYSTEM. VITROS GLUXT PATIENT SAMPLE RESULT OF <20 MG/DL VS. THE REPEAT RESULT OF 198 MG/DL BIASED RESULTS OF THE MAGNITUDE AND DIRECTION OBSERVED MAY LEAD TO INAPPROPRIATE PHYSICIAN ACTION IF THEY WERE TO OCCUR UNDETECTED. THE LOWER-THAN-EXPECTED GLUXT RESULT PREDICTED FROM THE PATIENT SAMPLE WAS NOT REPORTED OUTSIDE THE LABORATORY, AND THERE WAS NO ALLEGATION OF PATIENT HARM AS A RESULT OF THIS EVENT. THIS REPORT CORRESPONDS TO ORTHO CLINICAL DIAGNOSTICS INC (ORTHO) COMPLAINT NUMBER (B)(4) AND REPORTABILITY ASSESSMENT (B)(4).