inforMED
MalfunctionCEO

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 Diagnostics

Model number

NA

Catalog 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.