inforMED
MalfunctionJGS

REFERENCE ELECTRODE

Received Dec 18, 2024 · Event occurred Dec 3, 2024

Report 1823260-2024-03738 · MDR key 20968425

Device

Generic name

Ise Reference Electrode

Manufacturer

Roche Diagnostics

Catalog number

21029398001

Lot number

31235047

Product problems

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

Patient

NA · Unknown

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

Narrative

Additional Manufacturer Narrative

MEDWATCH FIELDS D1-D4, G1, AND G4 WERE UPDATED. THE FIELD SERVICE ENGINEER FOUND AN ISSUE WITH THE REFERENCE ELECTRODE TUBING AND FOUND FLUID UNDER THE ELECTRODES. HE REPLACED THE REFERENCE ELECTRODE, PERFORMED INITIALIZATION, AND PERFORMED MECHANICAL CHECKS. THE INVESTIGATION DETERMINED THE SERVICE ACTIONS RESOLVED THE ISSUE.

Description of Event or Problem

THERE WAS AN ALLEGATION OF QUESTIONABLE RESULTS FOR ONE PATIENT SAMPLE WITH THE NA ELECTRODE ON A COBAS INTEGRA 400 PLUS. THE INITIAL RESULT WAS 130.2 MMOL/L. THE REPEAT RESULT WAS 138.8 MMOL/L. THE REPEAT RESULT WAS DEEMED CORRECT.

Additional Manufacturer Narrative

THE SERIAL NUMBER OF THE ANALYZER WAS (B)(6) .THE INVESTIGATION IS ONGOING.