ABL827 FLEX
Received Mar 1, 2013 · Event occurred Nov 22, 2012
Report 3002807968-2013-00003 · MDR key 2992945
Device
Generic name
Abl827 Flex
Manufacturer
Radiometer Medical ApsModel number
ABL827 FLEXCatalog number
393-827
Product problems
- High Test Results
Patient
56 YR
- No Known Impact Or Consequence To Patient
Narrative
Additional Manufacturer Narrative
THE CUSTOMER SOLVED THE FIRST CAUSE OF THE PROBLEM BY REPLACING THE MEMBRANES. THERE WAS AN ERROR CODE '(951) - KREATINE LIGT ONDER DE RAPPORTEERGRENS' ON THE FIRST RESULT AFTER MEASUREMENT #(B)(6). OTHERWISE THERE ARE NO ERROR CODES IN CONNECTION WITH THE REGARDED MEASUREMENT RESULTS. IN THE QC-LOG THERE IS AN ERROR ON EVERY QC RESULT S7835 (LOW CREA, APPROX 200UM) BETWEEN 11/19/2012 AND 11/28/2012. THIS IS THE PERIOD WHERE THE REGARDED MEMBRANE WAS USED. THIS IS 14 FAILED OUT OF 30 QC RESULTS FOR THIS MEMBRANE. ON THE LAST QC MEASUREMENTS FOR THIS MEMBRANE THE S7855 ALSO FAILS (APPROX 600UM). IN THE CAL-LOG THERE ARE TWO BIG DRIFT3 ERRORS. ONE ON (B)(6) 2012 9:53 (-15, 6UM) AND ONE ON (B)(6) 2012 9:19 (-23, 1 UM). OTHERWISE NO ERRORS. THIS EVAL OF THE INSTRUMENT DATA POINTS TOWARDS A SINGLE DEFECT CREA-MEMBRANE. AS THE MEMBRANE WAS DISCARDED BY THE CUSTOMER, A ROOT CAUSE COULD NOT BE ESTABLISHED. THE CUSTOMER CAN CHOOSE IF THE ANALYZER SHOULD WARN ABOUT QC ERRORS ON THE PT RESULTS OR NOT, AND HOW QC ERRORS SHOULD AFFECT THE COLOR OF THE FRONT MENU TRAFFIC LIGHT. IT IS SUSPECTED THAT WARNINGS WERE DEACTIVATED IN THE INSTRUMENT SETUP. FURTHER INVESTIGATION IS ONGOING.
Description of Event or Problem
THE CUSTOMER COMPLAINED THAT PT RESULTS FOR CREA WERE TOO HIGH COMPARED WITH THE CLINICAL STATUS OF THE PT, WHILE QC VALUES WERE OK. CREA RESULTS WERE ALSO HIGHER THAN VALUES MEASURED ON A ROCHE MODULAR ANALYZER. AFTER REPLACING MEMBRANES THE VALUES WERE BETTER COMPARABLE. THERE WERE NO WARNING ABOUT FAILED QC'S ON THE PT RESULTS.