inforMED
MalfunctionCEK

TOTAL PROTEIN GEN.2

Received Jun 17, 2011 · Event occurred May 31, 2011

Report 1823260-2011-03324 · MDR key 2132768

Device

Generic name

Biuret (colorimetric), Total Protein

Manufacturer

Roche Diagnostics

Model number

NA

Catalog number

03183734190

Lot number

63870401

Product problems

  • High Test Results

Patient

045 YR

  • No Consequences Or Impact To Patient

Narrative

Additional Manufacturer Narrative

ADDITIONAL ASSAYS INVOLVED IN THIS EVENT ARE REPORTED ON THE MEDWATCH FORMS PATIENT IDENTIFIERS (B)(6).

Description of Event or Problem

THE USER EXPERIENCED CALIBRATION ERRORS AND FLAGGED RESULTS FOR PATIENT SAMPLES FROM THE INTEGRA 800 ANALYZER SERIAL NUMBER (B)(4). THE USER REPEATED TESTING OF THE PATIENT SAMPLES ON THE OTHER INTEGRA 800 ANALYZER SERIAL NUMBER (B)(4). OF THE DATA PROVIDED, THE TOTAL PROTEIN RESULTS FOR TWO PATIENT SAMPLES WERE DISCREPANT AND REPORTED OUTSIDE THE LABORATORY. PATIENT SAMPLE 1 INITIAL RESULT WAS 8.5 G/DL AND THE REPEAT RESULT WAS 7.0 G/DL. PATIENT SAMPLE 2 WAS FROM A FEMALE PATIENT BORN ON (B)(6). THE INITIAL RESULT WAS 9.1 G/DL AND THE REPEAT RESULT WAS 7.5 G/DL. THE PATIENTS WERE NOT ADVERSELY AFFECTED. UPON EVALUATION OF THE ANALYZER, THE FIELD SERVICE REPRESENTATIVE DETERMINED THERE WAS A DEFECTIVE AND DISCONNECTED LEVEL SENSE CABLE. HE REPLACED THE LIQUID LEVEL SENSE CABLE, WORN ROPES AND A BENT PROBE. HE CONNECTED THE VALVE CABLE ABOVE THE TRANSFER ARM TO THE REAGENT MODULE BODY. TO VERIFY THE ANALYZER OPERATION, HE RAN PERFORMANCE TESTING AND THE USER RAN AND VERIFIED QUALITY CONTROL.