PHOSPHOMOLYBDATE (COLORIMETRIC), INORGANIC PHOSPHORUS
Received May 6, 2015 · Event occurred Apr 8, 2015
Report 1823260-2015-03416 · MDR key 4752903
Device
Generic name
Phosphorus (inorganic) Test System
Manufacturer
Roche DiagnosticsModel number
NACatalog number
11730347216
Lot number
60023601
Product problems
- Incorrect Or Inadequate Test Results
Patient
Not reported
- No Consequences Or Impact To Patient
Narrative
Additional Manufacturer Narrative
CALIBRATION AND QUALITY CONTROLS WERE ACCEPTABLE. A SPECIFIC ROOT CAUSE COULD NOT BE IDENTIFIED. ADDITIONAL INFORMATION FOR FURTHER INVESTIGATION WAS REQUESTED BUT WAS NOT PROVIDED. THE MOST LIKELY ROOT CAUSE IS RELATED TO PRE-ANALYTICS OR AN ISSUE SPECIFIC TO EACH SAMPLE (E.G. DRUG INTERFERENCE).
Description of Event or Problem
THE CUSTOMER QUESTIONED INORGANIC PHOSPHORUS (PHOS) RESULTS FOR AN UNKNOWN NUMBER OF PATIENT SAMPLES. THE CUSTOMER IS QUESTIONING PHOS RESULTS BETWEEN REAGENT LOT 60023601 AND REAGENT LOT 61065701. THE SAMPLES WERE RUN AT THE CUSTOMER SITE USING BOTH LOT NUMBERS AND ALSO AT 2 DIFFERENT SITES WITH LOT 61065701. OF THE DATA PROVIDED FOR 49 PATIENT SAMPLES, 21 WERE ERRONEOUS. THE ERRONEOUS RESULTS WERE REPORTED OUTSIDE OF THE LABORATORY. THE INITIAL PHOS TESTS WERE RUN AT THE CUSTOMER SITE ON (B)(6) 2015 WITH REAGENT LOT 60023601. THESE RESULTS WERE REPORTED OUTSIDE OF THE LABORATORY. THE PHYSICIAN CALLED AND INDICATED THAT THE RESULTS WERE NOT WHAT HE EXPECTED TO SEE. THE SAMPLES WERE REPEATED ON (B)(6) 2015 AT THE CUSTOMER SITE AND 2 OTHER SITES USING REAGENT LOT 61065701. THE REPEAT RESULTS USING THE 2ND REAGENT LOT WERE CONSISTENT WITH WHAT THE PHYSICIAN EXPECTED TO SEE. NO ADVERSE EVENT OCCURRED. THE ANALYTICAL P MODULE SERIAL NUMBER WAS (B)(4). WATER SYSTEM MAINTENANCE WAS PERFORMED ON (B)(6) 2015. THE FIELD SERVICE ENGINEER CHECKED MULTIPLE PARTS OF THE INSTRUMENT AND COULD NOT LOCATE ANY ISSUES. THE VACUUM PUMP WAS REPLACED.
Additional Manufacturer Narrative
THIS EVENT OCCURRED IN (B)(6).
Additional Manufacturer Narrative
IT WAS NOTED THAT DURING A SERVICE VISIT, CONTAMINATED PROBES WERE IDENTIFIED DUE TO INSUFFICIENT FLUSHING INSIDE THE NOZZLE. AFTER REPLACING THE VALVES, REPLACING THE TUBING AND REMOVING THE WASHES PROBE, NO ADDITIONAL PHOS DISCREPANCIES OCCURRED.