inforMED
MalfunctionCDN

UNICEL DXC 600 PRO SYNCHRON SYSTEM

Received Mar 31, 2015 · Event occurred Mar 7, 2015

Report 2050012-2015-00115 · MDR key 4646552

Device

Generic name

Analyzer, Chemistry (photometric, Discrete), For Clinical Use

Manufacturer

Beckman Coulter

Model number

NA

Catalog number

A11810

Lot number

NA

Product problems

  • Fluid/Blood Leak
  • Device Operates Differently Than Expected

Patient

Not reported

  • No Known Impact Or Consequence To Patient

Narrative

Description of Event or Problem

CUSTOMER REPORTED THE UNICEL DXC 600 PRO SYNCHRON SYSTEM GENERATED ERRATIC AND SUPPRESSED RESULTS FOR BLOOD UREA NITROGEN (BUN) FOR PATIENT AND QUALITY CONTROL SAMPLES. CUSTOMER ALSO REPORTED REAGENT PROBE A WAS LEAKING. CUSTOMER REPORTED THE LEAK WAS ABOUT 15ML AND CONTAINED TO UNDER THE HOME POSITION OF THE REAGENT PROBE A. NO ERRONEOUS BUN RESULTS WERE REPORTED OUT OF THE LAB AND NO CHANGE IN TREATMENT OR HARM TO PATIENTS. NO EXPOSURE REPORTED. CUSTOMER WAS WEARING GLOVES.

Additional Manufacturer Narrative

A FIELD SERVICE ENGINEER (FSE) WAS DISPATCHED TO EVALUATE THE INSTRUMENT. FSE DETERMINED THE CAUSE OF THE ERRATIC AND SUPPRESSED BUN PATIENT AND QC RESULTS AS WELL AS THE REAGENT PROBE A LEAK WAS FROM REAGENT PROBE A COLLAR WASH VALVE. SERVICE REPLACED THE COLLAR WASH VALVE AND THAT RESOLVED THE ISSUE.