inforMED
MalfunctionCDX

T4

Received Apr 20, 2016 · Event occurred Mar 24, 2016

Report 1823260-2016-00455 · MDR key 5587344

Device

Generic name

Radioimmunoassay, Total Thyroxine

Manufacturer

Roche Diagnostics

Model number

NA

Catalog number

12017709122

Lot number

188364

Product problems

  • High Test Results
  • High Test Results

Patient

Not reported

  • No Consequences Or Impact To Patient
  • No Consequences Or Impact To Patient

Narrative

Additional Manufacturer Narrative

A SPECIFIC ROOT CAUSE COULD NOT BE DETERMINED BASED ON THE PROVIDED INFORMATION. A SAMPLE FROM THE PATIENT WAS REQUESTED FOR INVESTIGATION, BUT COULD NOT BE PROVIDED.

Additional Manufacturer Narrative

IT HAS BEEN CLARIFIED THAT THE ADVIA CENTAUR ANALYZER RESULTS OF 4.01 UIU/ML FOR TSH, 0.86 NG/ML FOR T3, AND 8.9 UG/DL FOR T4 FROM 03/24/2016 WERE REPORTED OUTSIDE OF THE LABORATORY.

Additional Manufacturer Narrative

THIS EVENT OCCURRED IN (B)(6).

Description of Event or Problem

THE CUSTOMER REPORTED THAT THEY RECEIVED ERRONEOUS RESULTS FOR TWO SAMPLES FROM THE SAME PATIENT TESTED FOR THYROTROPIN (TSH), FREE TRIIODOTHYRONINE (FT3), FREE THYROXINE (FT4), TRIIODOTHYRONINE (T3), AND THYROXINE (T4) ON AN E601 ANALYZER. THE E601 RESULTS WERE DIFFERENT WHEN COMPARED TO THE RESULTS FROM AN ADVIA CENTAUR ANALYZER. IT WAS ASKED, BUT IT IS NOT KNOWN IF ANY ERRONEOUS RESULTS WERE REPORTED OUTSIDE OF THE LABORATORY. THIS MEDWATCH WILL COVER T4. PLEASE REFER TO THE MEDWATCH WITH PATIENT IDENTIFIER (B)(6) FOR INFORMATION RELATED TO T3, REFER TO THE MEDWATCH WITH PATIENT IDENTIFIER (B)(6) FOR INFORMATION RELATED TO TSH, REFER TO THE MEDWATCH WITH PATIENT IDENTIFIER (B)(6) FOR INFORMATION RELATED TO FT3, REFER TO THE MEDWATCH WITH PATIENT IDENTIFIER (B)(6) FOR INFORMATION RELATED TO FT4. THE FIRST SAMPLE INITIALLY RESULTED AS 0.312 UIU/ML FOR TSH, 4.85 NG/ML FOR T3, AND 17.42 UG/DL FOR T4 WHEN TESTED ON THE E601 ANALYZER. THE SAMPLE WAS REPEATED ON AND ADVIA CENTAUR ANALYZER ON (B)(6) 2016, RESULTING AS 4.01 UIU/ML FOR TSH, 0.86 NG/ML FOR T3, AND 8.9 UG/DL FOR T4. THE SAMPLE WAS REPEATED AGAIN ON A SECOND E601 ANALYZER AT A SECOND LABORATORY ON (B)(6) 2016, RESULTING AS 0.288 UIU/ML FOR TSH, 6.51 NG/ML FOR T3, AND 21.33 UG/DL FOR T4. THE SAMPLE WAS REPEATED AGAIN ON A SECOND E601 ANALYZER AT A SECOND LABORATORY ON (B)(6) 2016, RESULTING AS 12.65 PG/ML FOR FT3 AND 4.66 NG/DL FOR FT4. THE SAMPLE WAS REPEATED AGAIN ON THE ORIGINAL E601 ANALYZER ON (B)(6) 2016, RESULTING AS 0.158 UIU/ML FOR TSH, 3.55 NG/ML FOR T3, 15.45 UG/DL FOR T4, 8.94 PG/ML FOR FT3, AND 3.73 NG/DL ON FT4. THE SAMPLE WAS REPEATED AGAIN ON THE ADVIA CENTAUR ANALYZER ON (B)(6) 2016, RESULTING AS 1.86 UIU/ML FOR TSH, 0.74 NG/ML FOR T3, 8.7 UG/DL FOR T4, 2.90 PG/ML FOR FT3, AND 1.36 NG/DL FOR FT4. THE SAMPLE WAS ALSO REPEATED AGAIN ON A THIRD E601 ANALYZER AT A THIRD LABORATORY ON (B)(6) 2016, RESULTING AS 0.225 UIU/ML FOR TSH, 317.1 NG/DL FOR T3, 16.96 UG/DL FOR T4, 8.88 PG/ML FOR FT3, AND 3.42 NG/DL FOR FT4. THE SECOND SAMPLE INITIALLY RESULTED AS 0.202 UIU/ML FOR TSH, 4.50 NG/ML FOR T3, 14.62 UG/DL FOR T4, 8.72 PG/ML FOR FT3, AND 3.85 NG/DL ON FT4. THE SECOND SAMPLE WAS REPEATED ON AN ADVIA CENTAUR ANALYZER ON (B)(6) 2016, RESULTING AS 2.0 UIU/ML FOR TSH, 0.78 NG/ML FOR T3, 8.7 UG/DL FOR T4, 2.82 PG/ML FOR FT3, AND 1.39 NG/DL FOR FT4. THE PATIENT WAS NOT ADVERSELY AFFECTED. THE E601 ANALYZER USED AT THE CUSTOMER SITE WAS SERIAL NUMBER (B)(4). THE E601 ANALYZER USED AT THE SECOND LABORATORY WAS SERIAL NUMBER (B)(4). THE E601 ANALYZER USED AT THE THIRD LABORATORY WAS SERIAL NUMBER (B)(4).