inforMED
MalfunctionMLM

ELECSYS TACROLIMUS

Received Dec 19, 2025 · Event occurred Dec 1, 2025

Report 1823260-2025-05233 · MDR key 23850301

Device

Generic name

Tacrolimus Immunoassay

Manufacturer

Roche Diagnostics

Catalog number

07251254190

Lot number

83481400

Product problems

  • Incorrect, Inadequate or Imprecise Result or Readings
  • High Test Results
  • Low Test Results
  • Non Reproducible Results
  • Incorrect, Inadequate or Imprecise Result or Readings
  • High Test 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

THE MEASURING CELL WAS EXCHANGED ON (B)(6) 2025. A GENERAL REAGENT ISSUE CAN BE EXCLUDED SINCE THE QC WAS WITHIN THE RANGES ON THE DAY OF THE EVENT. THE FIELD SERVICE ENGINEER PERFORMED A LIQUID FLOW CLEANING. NO FURTHER ISSUES WERE REPORTED AFTER THE SERVICE VISIT. THE INVESTIGATION DID NOT IDENTIFY A PRODUCT PROBLEM. THE CAUSE OF THE EVENT WAS CONSISTENT WITH A NON-OPTIMAL CUSTOMER INSTRUMENT MAINTENANCE.

Additional Manufacturer Narrative

THE TACROLIMUS REAGENT EXPIRATION DATE WAS NOT PROVIDED. THE COBAS E 801 MODULE SERIAL NUMBER WAS (B)(6) THE QC WAS ACCEPTABLE. THE INVESTIGATION IS ONGOING.

Description of Event or Problem

WE RECEIVED AN ALLEGATION ABOUT DISCREPANT RESULTS FOR 6 PATIENTS' SAMPLES TESTED WITH ELECSYS TACROLIMUS ASSAY ON A COBAS E 801 MODULE. SAMPLE 1: INITIAL RESULT: >40 UG/L. REPEAT RESULT: 11.3 UG/L. SAMPLE 2: INITIAL RESULT: >40 UG/L. REPEAT RESULT: 10.7 UG/L. SAMPLE 3: INITIAL RESULT: >40 UG/L. REPEAT RESULT: 10.1 UG/L. SAMPLE 4: INITIAL RESULT: >40 UG/L. REPEAT RESULT: 11.6 UG/L. SAMPLE 5: INITIAL RESULT: >40 UG/L. REPEAT RESULT: 12.8 UG/L. SAMPLE 6: INITIAL RESULT: >40 UG/L. REPEAT RESULT: 15.7 UG/L. THE PHYSICIAN QUESTIONED THE INITIAL RESULTS AND REQUESTED THAT THE SAMPLES BE REPEATED. THE REPEAT RESULTS WERE DEEMED TO BE CORRECT.