inforMED
MalfunctionCDX

T4

Received Oct 12, 2015 · Event occurred Sep 16, 2015

Report 1823260-2015-04312 · MDR key 5144144

Device

Generic name

Radioimmunoassay, Total Thyroxine

Manufacturer

Roche Diagnostics

Model number

NA

Catalog number

12017709122

Lot number

182845

Product problems

  • Incorrect Or Inadequate Test Results

Patient

063 YR

  • No Consequences Or Impact To Patient

Narrative

Additional Manufacturer Narrative

THIS EVENT OCCURRED IN (B)(6). (B)(6).

Description of Event or Problem

THE CUSTOMER COMPLAINED OF ERRONEOUS RESULTS FOR 1 PATIENT TESTED FOR THYROTROPIN (TSH), TRIIODOTHYRONINE (T3), FREE TRIIODOTHYRONINE (FT3), THYROXINE (T4), AND FREE THYROXINE (FT4). THE ERRONEOUS RESULTS WERE REPORTED OUTSIDE OF THE LABORATORY. THIS MEDWATCH WILL COVER T4. REFER TO MEDWATCH WITH PATIENT IDENTIFIER (B)(6) FOR INFORMATION ON THE TSH ERRONEOUS RESULTS, MEDWATCH WITH PATIENT IDENTIFIER (B)(6) FOR INFORMATION ON THE T3 ERRONEOUS RESULTS, MEDWATCH WITH PATIENT IDENTIFIER (B)(6) FOR INFORMATION ON THE FT3 ERRONEOUS RESULTS, AND MEDWATCH WITH PATIENT IDENTIFIER (B)(6) FOR INFORMATION ON THE FT4 ERRONEOUS RESULTS. ON (B)(6) 2015, THE PHYSICIAN COMPLAINED THAT THYROID RESULTS OBTAINED ON AN E602 ANALYZER FOR THIS PATIENT DID NOT CORRESPOND TO HIS CLINICAL CONDITION. ON (B)(6) 2015, THE PATIENT HAD A TSH RESULT OF 0.93 UIU/ML, A T3 RESULT OF 160.4 NG/DL, AN FT3 RESULT OF 17.98 PG/ML, A T4 RESULT > 24.86 UG/DL AND AN FT4 RESULT >7.77 NG/DL. THIS SAMPLE WAS DILUTED 1:2 BY USING POLYETHYLENE-GLYCOL (PEG) PRECIPITATION AND THE TSH RESULT WAS 2.68 UIU/ML, THE T3 RESULT WAS 185.22 NG/DL, FT3 RESULT WAS 3.62 PG/ML, T4 RESULT WAS 11.12 UG/DL AND FT4 RESULT WAS 2.76 NG/DL. ON (B)(6) 2015, A NEW SAMPLE WAS OBTAINED AND TESTED ON THE E602 ANALYZER. THE INITIAL TSH RESULT WAS 0.92 UIU/ML, THE T3 RESULT WAS 153.3 NG/DL, THE FT3 RESULT WAS 15.83 PG/ML, THE T4 RESULT WAS >24.86 UG/DL AND THE FT4 RESULT WAS >7.77 NG/DL. THE SAMPLE WAS REPEATED ON AN ARCHITECT INSTRUMENT AND THE TSH RESULT WAS 2.6519 UIU/ML, THE T3 RESULT WAS 52.36 NG/DL, THE FT3 RESULT WAS 1.38 PG/ML, THE T4 RESULT WAS 8.9 UG/DL AND THE FT4 RESULT WAS 1.09 NG/DL. ON (B)(6) 2015, AN ADDITIONAL SAMPLE WAS TESTED ON THE E602 ANALYZER. THE TSH RESULT WAS 1.000 UIU/ML, THE T3 RESULT WAS 169.2 NG/DL, THE FT3 RESULT WAS 16.3 PG/ML, THE T4 RESULT WAS >24.86 UG/DL AND THE FT4 RESULT WAS >7.77 NG/DL. NO ADVERSE EVENT OCCURRED. THE E602 ANALYZER SERIAL NUMBER WAS (B)(4). ON (B)(6) 2015, THE APPLICATION SPECIALIST VISITED THE SITE AND THE INTERNAL QUALITY CONTROLS WERE ACCEPTABLE.

Additional Manufacturer Narrative

AN ADDITIONAL SAMPLE WAS OBTAINED FOR THIS PATIENT ON (B)(4) 2015. THE PATIENT WAS TESTED ON THE E602 ANALYZER AND THE TSH RESULT WAS 1.45 UIU/ML, THE T3 RESULT WAS 280.2 NG/DL, THE FT3 RESULT WAS 15.3 PG/ML, THE T4 RESULT WAS >24.86 UG/DL, AND THE FT4 RESULT WAS 7.77 NG/DL.

Additional Manufacturer Narrative

THE EXPIRATION DATE FOR T4 WAS PROVIDED AS 07/2016.

Additional Manufacturer Narrative

THE SAMPLE WAS SUBMITTED FOR INVESTIGATION. INVESTIGATION CONFIRMED THE PRESENCE OF A STREPTAVIDIN INTERFERING FACTOR. THIS SPECIFIC INTERFERENCE IS ADDRESSED IN PRODUCT LABELING.