inforMED
MalfunctionCEO

PHOS2

Received Oct 1, 2024 · Event occurred Sep 9, 2024

Report 1823260-2024-02841 · MDR key 20348054

Device

Generic name

Phosphomolybdate (colorimetric), Inorganic Phosphorus

Manufacturer

Roche Diagnostics

Catalog number

03183793122

Lot number

782232, 801953

Product problems

  • Low Test Results
  • Low Test Results

Patient

75 YR · Male

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

Narrative

Additional Manufacturer Narrative

THE CUSTOMER WAS USING PHOSPHORUS REAGENT LOT 78223201 (EXPIRATION DATE = 31-MAY-2025) ON 09-SEP-2024. THE CUSTOMER STARTED USING PHOSPHORUS REAGENT LOT NUMBER 801953 ON 01-OCT-2024. THE EXPIRATION DATE FOR THIS LOT NUMBER WAS NOT PROVIDED. THE SAME PATIENT HAD 3 ADDITIONAL SAMPLES TESTED ON BOTH ANALYZERS, RESULTING IN THE FOLLOWING VALUES: A SAMPLE COLLECTED FROM THE PATIENT (SAMPLE 2) ON (B)(6) 2024 RESULTED IN A PHOSPHORUS VALUE OF < 0.176 MG/DL WITH A DATA FLAG ON (B)(6) 2024. THE SAMPLE WAS REPEATED ON A DIFFERENT C 501 ANALYZER, RESULTING IN A PHOSPHORUS VALUE OF 0.30 MG/DL ON (B)(6) 2024. A SECOND SAMPLE COLLECTED FROM THE PATIENT (SAMPLE 3) ON (B)(6) 2024 RESULTED IN A PHOSPHORUS VALUE OF 0.437 MG/DL ON (B)(6) 2024. A THIRD SAMPLE COLLECTED FROM THE PATIENT (SAMPLE 4) ON (B)(6) 2024 RESULTED IN A PHOSPHORUS VALUE OF 0.581 MG/DL ON (B)(6) 2024. MEDICATIONS WERE ADMINISTERED TO THE PATIENT PRIOR TO EACH SAMPLE COLLECTION. THE PATIENT HAS HAD NO HEALTH PROBLEMS DUE TO PHOSPHORUS LOADING. MEDWATCH FIELD D4 HAS BEEN UPDATED.

Additional Manufacturer Narrative

CALIBRATION AND CONTROLS WERE ACCEPTABLE. UPON REVIEW OF THE ALARM TRACE, 2 ABNORMAL ASPIRATION ALARMS OCCURRED NEAR THE TIME OF THE EVENT. BASED ON ANALYSIS OF THE REACTION DATA, AN ASSAY INTERFERENCE IS UNLIKELY. THE INVESTIGATION DETERMINED THAT THE ISSUE IS CONSISTENT WITH PHYSIOLOGICAL ALTERATIONS TO THE PATIENT'S PHOSPHORUS LEVELS BASED ON MEDICATIONS THE PATIENT WAS TAKING. THE PATIENT WAS TAKING FUROSEMIDE, WHICH CAN CAUSE HYPOPHOSPHATEMIA DUE TO INCREASED EXCRETION OF PHOSPHORUS IN THE URINE. THE PATIENT WAS ALSO TAKING PREDNISONE WHICH MAY CAUSE HYPOPHOSPHATEMIA BY AFFECTING PHOSPHORUS METABOLISM.

Additional Manufacturer Narrative

THE SERIAL NUMBER OF THE C501 ANALYZER IS (B)(6). THE SERIAL NUMBER OF THE C 503 ANALYZER WAS REQUESTED, BUT NOT PROVIDED. THE INVESTIGATION IS ONGOING. MEDWATCH FIELD E1 PHONE NUMBER WAS PROVIDED AS (B)(6).

Description of Event or Problem

THE INITIAL REPORTER STATED THEY RECEIVED QUESTIONABLE RESULTS FOR SAMPLES FROM THE SAME PATIENT TESTED WITH PHOS2 (PHOSPHORUS) ON A COBAS 6000 C501 MODULE AND A COBAS C 503 ANALYTICAL UNIT. AT LEAST 4 SAMPLES FROM THE PATIENT HAVE RESULTED IN PHOSPHORUS VALUES OF < 0.181 MG/DL ACCOMPANIED BY A DATA FLAG WHEN TESTED ON EITHER THE C 501 OR C 503 SYSTEMS. THE RESULTS DID NOT MATCH THE PATIENT'S CLINICAL DIAGNOSIS. DATA WAS PROVIDED FOR ONE SPECIFIC SAMPLE TESTED ON (B)(6) 2024. THIS SAMPLE INITIALLY RESULTED IN A PHOSPHORUS VALUE OF < 0.181 MG/DL ACCOMPANIED BY A DATA FLAG WHEN TESTED ON THE C 501 MODULE. THIS SAMPLE WAS SENT TO ANOTHER SITE WHERE IT WAS TESTED ON A VITROS ANALYZER, RESULTING IN A PHOSPHORUS VALUE OF 1.1 MG/DL.