CORTISOL
Received Aug 5, 2016 · Event occurred Jul 11, 2016
Report 1823260-2016-01115 · MDR key 5850920
Device
Generic name
Enzyme Immunoassay, Cortisol, Salivary
Manufacturer
Roche DiagnosticsModel number
NACatalog number
11875116122
Lot number
18538000
Product problems
- Incorrect Or Inadequate Test Results
- Incorrect Or Inadequate Test Results
Patient
Not reported
- No Consequences Or Impact To Patient
- 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 TESTED FOR CORTISOL AND CORTISOL II. THE ERRONEOUS RESULTS WERE BETWEEN THE CORTISOL TESTS RUN ON AN E601 ANALYZER AND CORTISOL II TESTS RUN ON AN E602 ANALYZER. THE CORTISOL RESULTS WERE REPORTED OUTSIDE OF THE LABORATORY WHERE THEY WERE QUESTIONED BY THE PHYSICIAN SINCE THEY DIDN'T MATCH THE PATIENT'S CLINICAL SYMPTOMS. THIS MEDWATCH WILL COVER CORTISOL. REFER TO MEDWATCH WITH (B)(6) FOR INFORMATION ON THE CORTISOL II ERRONEOUS RESULTS. THE INITIAL CORTISOL RESULT FROM THE E601 ANALYZER WAS 384.1 NMOL/L. THIS RESULT WAS REPORTED OUTSIDE OF THE LABORATORY. THE SAMPLE WAS REPEATED ON (B)(6) 2016 AND THE RESULT WAS 385.7 NMOL/L. A NEW SAMPLE WAS OBTAINED AND THE CORTISOL RESULT FROM THE E601 ANALYZER WAS 258.4 NMOL/L. THIS RESULT WAS REPORTED OUTSIDE OF THE LABORATORY. THE SAMPLE WAS REPEATED ON (B)(6) 2016 AND THE RESULT WAS 272.1 NMOL/L. BOTH SAMPLES WERE ALSO TESTED FOR CORTISOL II ON THE E602 ANALYZER. THE INITIAL SAMPLE WAS REPEATED TWICE AND THE CORTISOL II RESULTS WERE 1750 NMOL/L WITH A DATA FLAG AND 5658 NMOL/L. THE 2ND SAMPLE WAS REPEATED TWICE AND THE CORTISOL II RESULTS WERE 1750 NMOL/L WITH A DATA FLAG AND 2837 NMOL/L. THE BIOCHEMIST IS NOW QUESTIONING THE DIFFERENCE BETWEEN THE RESULTS FROM CORTISOL AND CORTISOL II AND WONDERING IF THERE COULD BE AN INTERFERENCE. OTHER PATIENTS WERE TESTED AND THE SAME BEHAVIOR WAS NOT OBSERVED. NO ADVERSE EVENT OCCURRED. THE E601 ANALYZER SERIAL NUMBER WAS NOT PROVIDED. THE E602 ANALYZER SERIAL NUMBER WAS NOT PROVIDED. A GENERAL REAGENT ISSUE IS NOT SUSPECTED BASED ON THE QUALITY CONTROL DATA PROVIDED. THE SAMPLE AND REAGENT HANDLING AT THE CUSTOMER SITE SEEMS TO BE IN ACCORDANCE WITH SPECIFICATIONS. A SPECIFIC ROOT CAUSE COULD NOT BE IDENTIFIED. ADDITIONAL INFORMATION WAS REQUESTED FOR INVESTIGATION BUT WAS NOT PROVIDED.