inforMED
MalfunctionJFP

ROCHE 9180 ELECTROLYTE ANALYZER

Received May 28, 2025 · Event occurred May 8, 2025

Report 1823260-2025-01629 · MDR key 22095181

Device

Generic name

Electrolyte Analyzer

Manufacturer

Roche Diagnostics

Catalog number

03157334001

Product problems

  • Incorrect, Inadequate or Imprecise Result or Readings
  • Incorrect, Inadequate or Imprecise Result or Readings

Patient

NA · Unknown

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

Narrative

Additional Manufacturer Narrative

THE ELECTRODE LOT NUMBER AND EXPIRATION DATE WERE NOT PROVIDED. THE FIELD SERVICE ENGINEER REPLACED THE SODIUM ELECTRODE, THE REFERENCE ELECTRODE, AND THE HOUSING. THE INVESTIGATION IS ONGOING.

Description of Event or Problem

THERE WAS AN ALLEGATION OF QUESTIONABLE SODIUM RESULTS FROM THE ELECTROLYTE ANALYZER W/O STARTERKIT 9180. THE INITIAL RESULT WAS 109 MMOL/L. THE SAMPLE WAS REPEATED MULTIPLE TIMES, AND THE RESULT WAS WITHIN 1 MMOL/L OF THE INITIAL RESULT. THE SAMPLE WAS THEN TESTED ON AN ALINITY ANALYZER, AND THE RESULT WAS 139 MMOL/L.

Additional Manufacturer Narrative

THE ROOT CAUSE OF THE ISSUE WAS RELATED TO A REFERENCE ELECTRODE MANUFACTURED BY DIAMOND DIAGNOSTICS (DD REF ELECTRODE) USED WITH THE 9180 ELECTROLYTE ANALYZER. THE REFERENCE ELECTRODE USED (DD REF ELECTRODE) IS COVERED BY A ROCHE INITIATED RECALL. CUSTOMERS USING THE DD REF ELECTRODE WERE INSTRUCTED TO IMMEDIATELY STOP USING SODIUM (NA) RESULTS FROM THEIR 9180 ANALYZER. THE AFFECTED REFERENCE ELECTRODE WAS NOT DISTRIBUTED IN THE UNITED STATES. CUSTOMERS IN THE UNITED STATES USE ROCHE REFERENCE ELECTRODE AND REFERENCE ELECTRODE HOUSING. NO FURTHER ACTION IS NEEDED FOR CUSTOMERS IN THE UNITED STATES.