inforMED
MalfunctionLPS

N LATEX HCY

Received Jan 17, 2017 · Event occurred Aug 31, 2016

Report 9610806-2017-00010 · MDR key 6258921

Device

Generic name

N Latex Hcy

Catalog number

OPAX032 SMN10445973

Lot number

802907632

Product problems

  • Low Test Results
  • Low Test Results

Patient

83 YR

  • No Known Impact Or Consequence To Patient
  • No Known Impact Or Consequence To Patient

Narrative

Additional Manufacturer Narrative

SIEMENS HEALTHCARE DIAGNOSTICS HAS OBSERVED A REDUCED ONCE-OPENED STABILITY AND A REDUCED ON-BOARD STABILITY FOR THE AFFECTED LOT 802907632 THAT MAY RESULT IN ERRONEOUSLY REDUCED OR ELEVATED HOMOCYSTEINE. THIS STABILITY ISSUE MAY LEAD TO A HIGHER THAN EXPECTED LOT-TO-LOT VARIATION AND IMPAIRED PRODUCT PERFORMANCE. URGENT MEDICAL DEVICE CORRECTION (UMDC) PP17-005.A.US WAS SENT TO CUSTOMERS IN THE UNITED STATES ON JANUARY 11, 2017 AND CORRESPONDING URGENT FIELD SAFETY NOTICE (UFSN) BR-01117_OUS WAS SENT TO ALL OUTSIDE US CUSTOMERS WHO HAVE BEEN SHIPPED THE IMPACTED LOT, 802907632. THE UMDC AND UFSN TITLED "N LATEX HCY AND N LATEX HCY (BCS® XP) LOT 802907632 DOES NOT MEET ONCE-OPENED AND ONBOARD STABILITY CLAIMS" AND INSTRUCTS CUSTOMERS TO DISCONTINUE USE AND TO DISCARD THE LOT.

Description of Event or Problem

DISCORDANT LOW HOMOCYSTEINE (HCY) RESULTS WERE OBTAINED SEVEN PATIENT SAMPLE ON THE BN PROSPEC INSTRUMENT. THE PATIENT RESULTS WERE NOT REPORTED TO THE PHYSICIAN. THE SAME SAMPLES WERE TESTED WITH AN ALTERNATE HCY LOT AND HIGHER RESULTS WERE OBTAINED AND REPORTED. ALL CONTROLS RUN WITH LOTS 802907632 AND 802909289 WERE WITHIN RANGE AND THAT THERE WERE NO INSTRUMENT ERRORS. THERE ARE NO REPORTS OF PATIENT INTERVENTION OR ADVERSE HEALTH CONSEQUENCES DUE TO THE DISCORDANT LOW HCY RESULTS.

Remedial action

  • Recall