inforMED
MalfunctionDHX

CARCINOEMBRYONIC ANTIGEN - CEA

Received Dec 28, 2015 · Event occurred Dec 4, 2015

Report 1823260-2015-06122 · MDR key 5329085

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Product code (DHX)
Manufacturer (Roche Diagnostics International Ltd.)
Model (NA)

Device

Generic name

System, Test, Carcinoembryonic Antigen

Manufacturer

Roche Diagnostics

Model number

NA

Catalog number

11731629322

Lot number

185168

Product problems

  • Low Test Results

Patient

Not reported

  • No Consequences Or Impact To Patient

Narrative

Additional Manufacturer Narrative

THIS EVENT OCCURRED IN (B)(6).

Description of Event or Problem

THE CUSTOMER COMPLAINED OF ERRONEOUS RESULTS FOR 1 PATIENT SAMPLE TESTED FOR CARCINOEMBRYONIC ANTIGEN (CEA). THE ERRONEOUS RESULTS WERE REPORTED OUTSIDE OF THE LABORATORY. THE INITIAL CEA RESULT WAS 600 NG/ML. THE SAMPLE WAS DILUTED MANUALLY X10 AND AUTOMATICALLY DILUTED X400 AND THE RESULT WAS 510,000 NG/ML. BOTH RESULTS WERE REPORTED OUTSIDE OF THE LABORATORY. IT WAS NOTED THAT THE HIGH RESULTS FOR CEA MATCH THE PHYSICAL CONDITION OF THE PATIENT. NO ADVERSE EVENT OCCURRED. THE E602 ANALYZER SERIAL NUMBER WAS NOT PROVIDED.

Additional Manufacturer Narrative

THE SAMPLE WAS SUBMITTED FOR INVESTIGATION. THE CUSTOMER'S VALUES WERE REPRODUCIBLE. THE MOST LIKELY ROOT CAUSE IS DUE TO A HIGH DOSE HOOK EFFECT DUE TO THE HIGH CEA CONCENTRATION IN THE SAMPLE. THE CEA CONCENTRATION IS ABOVE THE HIGH DOSE HOOK CONCENTRATION OF 200,000 NG/ML.