inforMED
MalfunctionNBC

TRIAGE CARDIAC PANEL

Received Apr 25, 2016 · Event occurred Mar 25, 2016

Report 2027969-2016-00239 · MDR key 5605570

Device

Generic name

Cardiac Marker Test,

Model number

97021HS

Lot number

W60560RB

Product problems

  • Incorrect, Inadequate or Imprecise Result or Readings
  • Low Readings
  • Incorrect, Inadequate or Imprecise Result or Readings
  • Low Readings

Patient

Not reported

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

Narrative

Additional Manufacturer Narrative

PRODUCT CODE: DDR, JHX AND MMI. INVESTIGATION/CONCLUSION: THE CUSTOMER'S COMPLAINT OF DISCREPANT LOW TNI ON LOT W60560 WAS NOT REPLICATED WITH IN-HOUSE CALIBRATOR TESTING. THE LOT MET CARDIAC TNI FINAL RELEASE SPECIFICATIONS. THE RETURNED PATIENT SAMPLE YIELDED TNI RESULTS CLOSE TO THE CUSTOMER'S OBSERVED 0.13 NG/ML WHEN TESTED IN-HOUSE. ACCORDING TO PACKAGE INSERT TRIAGE TNI RANGE, THIS IS AN "ABNORMAL RESULT" AND WOULD PROVIDE THE SAME CLINICAL OUTCOME AS THE LABORATORY RESULTS. BATCH RECORD FOR LOT W60560 WAS REVIEWED AND THE LOT MET ALL CARDIAC HS TNI ONLY FINAL RELEASE SPECIFICATIONS. BASED ON THE INFORMATION AVAILABLE, THERE IS NO INDICATION OF A PRODUCT DEFICIENCY AND NO CORRECTIVE ACTION IS REQUIRED.

Description of Event or Problem

THE CUSTOMER ALLEGED A VARIANCE BETWEEN THE TRIAGE TROPONIN I (TNI) RESULTS AND THE LABORATORY TNI RESULTS. THE PATIENT WAS ADMITTED THROUGH THE EMERGENCY DEPARTMENT. THERE WAS NO DIAGNOSIS PROVIDED. REFERENCE TNI RANGES: TRIAGE 0.0-0.4 / LABORATORY 0.00-0.057. ON (B)(6) 2016 8:05AM: TRIAGE TNI NOT TESTED; LABORATORY TNI=0.68; ON (B)(6) 2016 12:14PM: SAMPLE SENT TO ANOTHER LABORATORY=0.25 (INSTRUMENT UNKNOWN); ON (B)(6) 2016 3:20PM: TRIAGE TNI=0.13 (SAME TUBE) / LABORATORY TNI=0.572; ON (B)(6) 2016 8:20PM: TRIAGE NOT TESTED / DIMENSION=0.558; ON (B)(6) 2016 ~7:00AM: TRIAGE TNI=0.09 (SAME TUBE), LABORATORY TNI NOT TESTED (ANALYZER DOWN). THE CUSTOMER STATED THAT THE PATIENT WAS TREATED FROM THE LABORATORY RESULTS AND NOT THE TRIAGE RESULTS. THERE WAS NO ADVERSE PATIENT SEQUELA AND NO ADDITIONAL INFORMATION REPORTED.