inforMED
MalfunctionJGS

NA ELECTRODE

Received Dec 5, 2024 · Event occurred Nov 14, 2024

Report 1823260-2024-03531 · MDR key 20854462

Device

Generic name

Electrode, Ion Specific, Sodium

Manufacturer

Roche Diagnostics

Catalog number

10825468001

Lot number

V81

Product problems

  • Low Test Results
  • Non Reproducible Results
  • Low Test Results
  • Non Reproducible Results

Patient

78 YR · Male

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

Narrative

Additional Manufacturer Narrative

THE ELECTRODE LOT NUMBER WAS B8165. THE EXPIRATION DATE WAS NOT PROVIDED. THE COBAS 6000 C 501 SERIAL NUMBER WAS (B)(6). THE FIELD SERVICE ENGINEER COULD NOT REPRODUCE THE ISSUE OR FIND A SPECIFIC CAUSE. HE REPLACED THE DEGASSER TANK, A VALVE, THE BATH SUB-ASSEMBLY, AND THE INTERNAL STANDARD BATH. THE CUSTOMER REPLACED THE POTASSIUM ELECTRODE. HE PERFORMED ISE CHECKS THAT WERE ACCEPTABLE AND THE CUSTOMER PERFORMED QC. THE CUSTOMER RECALIBRATED WITH A NEW LOT (81526901) OF INTERNAL STANDARD WHICH APPEARED TO RESOLVE THE ISSUE. THE INVESTIGATION IS ONGOING.

Description of Event or Problem

THERE WAS AN ALLEGATION OF QUESTIONABLE SODIUM RESULTS FROM THE COBAS 6000 C 501 MODULE. THE INITIAL RESULT WAS 134 MMOL/L AND THE REPEAT RESULT FROM ANOTHER COBAS C501 ANALYZER WAS 141 MMOL/L. THE REPEAT RESULT WAS BELIEVED TO BE CORRECT.

Additional Manufacturer Narrative

THE FIELD SERVICE ENGINEER REPLACED THE DEGASSER TANK, MULTIPLE VALVES, BATH ASSEMBLY, INTERNAL STANDARD BATH, AND OTHER VARIOUS PARTS. THE CUSTOMER REPLACED THE POTASSIUM ELECTRODE. FOR VERIFICATION, ISE CHECKS AND PRECISION WERE PERFORMED WITH ACCEPTABLE RESULTS. THE ANALYZER ALARM TRACE CONTAINED ABNORMAL PROBE SUCKING AND SAMPLE SHORT ERRORS. THESE ARE INDICATORS OF POSSIBLE POOR SAMPLE QUALITY. CORRECT PRE-ANALYTIC SAMPLE HANDLING IS WITHIN THE CUSTOMER'S RESPONSIBILITY. THE INVESTIGATION DID NOT IDENTIFY THE SPECIFIC CAUSE OF THE EVENT. THE ISSUE APPEARED TO BE RESOLVED AFTER THE SERVICE ACTIONS.