inforMED
MalfunctionNIG

ELECSYS CA 19-9

Received May 30, 2025 · Event occurred May 5, 2024

Report 1823260-2025-01672 · MDR key 22116019

Device

Generic name

Test, Carbohydrate Antigen (ca19-9)

Manufacturer

Roche Diagnostics

Catalog number

11776193122

Lot number

782391

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

Description of Event or Problem

THERE WAS AN ALLEGATION OF A QUESTIONABLE ELECSYS CA 19-9 RESULT FROM THE COBAS E 411 ANALYZER (DISK SYSTEM). THE INITIAL RESULT ON (B)(6) 2025 WAS <0.6 U/ML, AND THE REPEAT RESULT WAS 49.54 U/ML.

Additional Manufacturer Narrative

THE COBAS E 411 ANALYZER (DISK SYSTEM) SERIAL NUMBER IS (B)(6). THE LAST CALIBRATIONS PROVIDED WAS PERFORMED ON 01-AUG-2024, WHICH IS NOT THE RECOMMENDED INTERVAL. QC DATA WAS NOT PROVIDED. THE ALARM TRACE WAS NOT PROVIDED FOR THE DATE OF THE EVENT. THE INVESTIGATION IS ONGOING.

Additional Manufacturer Narrative

A FIELD SERVICE ENGINEER (FSE) PERFORMED AN ARTIFICIAL MEDIA TEST (AM TEST), AND IT FAILED FOR DILUTION 1:20 PRECISION. DUE TO THIS ISSUE, THE SAMPLE PROBE WAS REPLACED, AND THE TEST WAS REPEATED. THE SECOND AM TEST PASSED COMPLETELY. THE ALARM TRACE THAT WAS PROVIDED WAS NOT FROM THE RANGE OF TIME OF THE EVENT. HOWEVER, THERE WERE SEVERAL OCCURRENCES OF SAMPLE QUALITY-RELATED ALARMS, SUCH AS INSUFFICIENT SAMPLE OR PIPETTE CLOG, WHICH IS CONSISTENT WITH PRE-ANALYTICAL ISSUES. THE INVESTIGATION WAS UNABLE TO DETERMINE A DIRECT ROOT CAUSE.