inforMED
MalfunctionDHX

COBAS E411 RACK SYSTEM

Received Jun 9, 2014 · Event occurred May 22, 2014

Report 1823260-2014-04166 · MDR key 3856120

Device

Generic name

Immunochemistry Analyzer

Manufacturer

Roche Diagnostics

Model number

NA

Catalog number

04775201001

Lot number

NA

Product problems

  • High Test Results

Patient

067 YR

  • No Consequences Or Impact To Patient

Narrative

Additional Manufacturer Narrative

NO ROOT CAUSE COULD BE DETERMINED. THE FIELD SERVICE REPRESENTATIVE FOUND THAT THE PERFORMANCE TESTING RESULTS WERE WITHIN RANGE, BUT THE MEASURING CELL CARRYOVER WAS HIGH. THE MEASURING CELL WAS REPLACED AND THE HIGH VOLTAGE WAS ADJUSTED. ANOTHER PERFORMANCE TEST WAS DONE WITH RESULTS WITHIN RANGE. THE INSTRUMENT WAS WORKING WITHIN SPECIFICATION.

Description of Event or Problem

THE CUSTOMER ALLEGED THEY RECEIVED A QUESTIONABLE CARCINOEMBRYONIC ANTIGEN (CEA) RESULT FOR ONE PATIENT ON THEIR E411 ANALYZER. THE PATIENT'S INITIAL CEA RESULT WAS 7.6 NG/ML AND IT WAS REPORTED OUTSIDE THE LABORATORY. THE SAMPLE WAS REPEATED ON AN ADVIA CENTAUR IN ANOTHER LABORATORY, AND THE RESULT WAS 1.4 NG/ML. THERE WERE NO ADVERSE EVENTS. THE CEA REAGENT LOT NUMBER AND EXPIRATION DATE WERE REQUESTED BUT NOT PROVIDED.

Additional Manufacturer Narrative

THIS EVENT OCCURRED IN (B)(6).