inforMED
MalfunctionDHX

CEA ELECSYS

Received Mar 28, 2017 · Event occurred Mar 1, 2017

Report 1823260-2017-00655 · MDR key 6439977

Device

Generic name

System, Test, Carcinoembryonic Antigen

Manufacturer

Roche Diagnostics

Model number

NA

Catalog number

11731629322

Lot number

ASKU

Product problems

  • Low Test Results
  • Low Test Results

Patient

Not reported

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

Narrative

Additional Manufacturer Narrative

(B)(4). (B)(6).

Description of Event or Problem

THE CUSTOMER RECEIVED QUESTIONABLE RESULTS FOR ONE PATIENT USING THE ELECSYS CEA ASSAY ON AN UNSPECIFIED COBAS ELECSYS SYSTEM. THE CUSTOMER INQUIRED ABOUT PUBLISHED LITERATURE THAT DESCRIBED THE DIFFERENCE BETWEEN A TRUE ZERO RESULT AND A FALSE ZERO RESULT IN IMMUNOLOGY TESTING. THE CUSTOMER THEN PROVIDED RESULTS. THE INITIAL RESULT WAS <0.2 NG/ML. THE REPEAT RESULT WAS 70 NG/ML WHICH WAS CONSIDERED CORRECT. IT IS UNKNOWN WHETHER THESE RESULTS WERE REPORTED TO MEDICAL PERSONNEL. THE CUSTOMER WOULD NOT PROVIDE ANY ADDITIONAL INFORMATION. THERE WAS NO ALLEGATION OF AN ADVERSE EVENT WITH THE PATIENT. THE ELECSYS ANALYZER INFORMATION WAS NOT PROVIDED. A SPECIFIC ROOT CAUSE COULD NOT BE IDENTIFIED. ADDITIONAL INFORMATION FOR FURTHER INVESTIGATION WAS REQUESTED BUT WAS NOT PROVIDED. POSSIBLE ROOT CAUSES FOR THIS EVENT MAY BE SAMPLE QUALITY AND INSUFFICIENT MAINTENANCE.