inforMED
MalfunctionCFJ

LDHI2 LACTATE DEHYDROGENASE

Received Jan 24, 2018 · Event occurred Jan 9, 2018

Report 1823260-2018-00228 · MDR key 7216397

Device

Generic name

Lactate Dehydrogenase Test System

Manufacturer

Roche Diagnostics

Model number

NA

Catalog number

05169330190

Lot number

280352

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

(B)(4).

Description of Event or Problem

THE CUSTOMER RECEIVED QUESTIONABLE LDHI2 LACTATE DEHYDROGENASE RESULTS FOR MULTIPLE PATIENT SAMPLES AFTER MONTHLY MAINTENANCE WAS PERFORMED ON COBAS 8000 C 702 MODULE SERIAL NUMBER (B)(4). MOST OF THE RESULTS WERE ACCOMPANIED BY DATA FLAGS. OF THE DATA PROVIDED FOR 10 PATIENT SAMPLES, ONLY THE RESULTS FOR THREE PATIENT SAMPLES WERE DISCREPANT. PATIENT 1: INITIAL RESULT WAS 440 U/L AND THE REPEAT RESULTS FROM OTHER COBAS 8000 C 702 MODULES ON (B)(6) 2018 WERE 215 U/L AND 213 U/L. PATIENT 2: INITIAL RESULT WAS 376 U/L AND THE REPEAT RESULTS FROM OTHER COBAS 8000 C 702 MODULES WERE 188 U/L AND 188 U/L. PATIENT 3: INITIAL RESULT WAS 398 U/L AND THE REPEAT RESULTS FROM OTHER COBAS 8000 C 702 MODULES WERE 240 U/L AND 240 U/L. NO ERRONEOUS RESULT WAS REPORTED OUTSIDE OF THE LABORATORY. THERE WAS NO ADVERSE EVENT. AS NO OTHER ENZYMATIC ASSAYS HAD ISSUES, THE CUSTOMER SUSPECTED THERE WAS AN ISSUE WITH THE REAGENT PACK. THE CUSTOMER REPLACED THE REAGENT PACK WHICH RESOLVED THE ISSUE.

Additional Manufacturer Narrative

FOLLOW UP WITH THE CUSTOMER CONFIRMED THE ISSUE WAS RESOLVED BY REPLACEMENT OF THE REAGENT PACK. A QUERY WAS PERFORMED AND FOUND NO PAST ESCALATED COMPLAINTS OF THIS NATURE ON ANY LIKE INSTRUMENTS FOR THE LAST 12 MONTHS AT THIS SITE.