inforMED
MalfunctionJGS

NA ELECTRODE

Received Dec 16, 2024 · Event occurred Nov 23, 2024

Report 1823260-2024-03700 · MDR key 20945057

Device

Generic name

Electrode, Ion Specific, Sodium

Manufacturer

Roche Diagnostics

Catalog number

10825468001

Lot number

AKY70

Product problems

  • Incorrect, Inadequate or Imprecise Result or Readings
  • High Test Results
  • Incorrect, Inadequate or Imprecise Result or Readings
  • High Test Results

Patient

NA · Unknown

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

Narrative

Additional Manufacturer Narrative

THE INVESTIGATION DID NOT IDENTIFY A PRODUCT PROBLEM. THE CAUSE OF THE EVENT COULD NOT BE DETERMINED.

Description of Event or Problem

THERE WAS AN ALLEGATION OF QUESTIONABLE NA ELECTRODE RESULTS FOR 2 PATIENT SAMPLE(S) ON A COBAS PRO ISE ANALYTICAL UNIT. PATIENT 1: THE INITIAL NA RESULT WAS 147.4 MMOL/L AND THE REPEATED RESULT WAS 139.1 MMOL/L. PATIENT 2: THE INITIAL NA RESULT WAS 143.8 MMOL/L AND THE REPEATED RESULT WAS 134.4 MMOL/L. THE REPEATED RESULTS WERE OBTAINED ON ANOTHER MODULE AND WERE BELIEVED TO BE CORRECT. THE SAMPLES WERE REPEATED DUE TO A DELTA CHECK IN THE CUSTOMER'S SYSTEM.

Additional Manufacturer Narrative

THE ANALYZER'S SERIAL NUMBER IS (B)(6). THE FIELD SERVICE REPRESENTATIVE INSPECTED/CHECKED THE INSTRUMENT AND VERIFIED IT WAS PERFORMING WITHIN SPECIFICATIONS. NO ABNORMALITIES WERE OBSERVED WITH THE INSTRUMENT. HE REPLACED THE ELECTRODES AND PERFORMED TESTS WITH ACCEPTABLE RESULTS. THE INVESTIGATION IS ONGOING.