inforMED
MalfunctionMLM

ELECSYS TACROLIMUS

Received Feb 4, 2025 · Event occurred Jan 13, 2025

Report 1823260-2025-00330 · MDR key 21307380

Device

Generic name

Tacrolimus Immunoassay

Manufacturer

Roche Diagnostics

Catalog number

07251254190

Lot number

75323400

Product problems

  • Low Test Results
  • Output Problem
  • Non Reproducible Results
  • Low Test Results
  • Output Problem
  • Non Reproducible Results

Patient

NA · Unknown

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

Narrative

Description of Event or Problem

THERE WAS AN ALLEGATION OF QUESTIONABLE ELECSYS TACROLIMUS RESULTS FROM THE COBAS E 801 ANALYTICAL UNIT. THE INITIAL RESULT WAS 0.5 NG/ML WITH A DATA FLAG. ON (B)(6) 2025, THE REPEAT RESULT WAS 10.1 NG/ML. ON (B)(6) 2025, A NEW SAMPLE WAS DRAWN FROM THE PATIENT AND THE RESULT WAS 13.0 NG/ML.

Additional Manufacturer Narrative

THE COBAS E 801 ANALYTICAL UNIT SERIAL NUMBER WAS (B)(6). THE INVESTIGATION IS ONGOING.

Additional Manufacturer Narrative

THE CALIBRATION RESULTS WERE WITHIN SPECIFICATIONS BUT WERE IN THE LOW RANGE. THE QC WAS WITHIN SPECIFICATIONS ON THE DATE OF EVENT. BASED ON THE "SAMPLE ASPIRATION ALARM" PRESENT DURING SAMPLE PIPETTING, THE INVESTIGATION DETERMINED THE ISSUE WAS DUE TO PRE-ANALYTICAL HANDLING ISSUES AT THE CUSTOMER SITE. CORRECT PRE-ANALYTIC SAMPLE HANDLING IS WITHIN THE CUSTOMER'S RESPONSIBILITY. A GENERAL REAGENT PROBLEM WAS NOT PRESENT, BECAUSE THE QC BEFORE THE EVENT WAS WITHIN RANGES THERE IS NO EVIDENCE TO SUGGEST A MALFUNCTION OF THE DEVICE.