CEA ELECSYS
Received Jun 26, 2018 · Event occurred Jun 5, 2018
Report 1823260-2018-02045 · MDR key 7638730
Device
Generic name
System, Test, Carcinoembryonic Antigen
Manufacturer
Roche DiagnosticsModel number
NACatalog number
11731629322
Lot number
ASKU
Product problems
- Incorrect Or Inadequate Test Results
- Incorrect Or Inadequate Test Results
Patient
87 YR
- No Consequences Or Impact To Patient
- No Consequences Or Impact To Patient
Narrative
Additional Manufacturer Narrative
THE INVESTIGATION WAS UNABLE TO FIND A DEFINITIVE ROOT CAUSE.
Additional Manufacturer Narrative
THIS EVENT OCCURRED IN (B)(6). UNIQUE IDENTIFIER (UDI)#: (B)(4).
Description of Event or Problem
THE CUSTOMER STATED THAT THEY RECEIVED QUESTIONABLE RESULTS FOR A TOTAL OF 245 PATIENT SAMPLES TESTED ON A ROCHE DIAGNOSTICS ELECSYS E170 MODULAR ANALYTICS IMMUNOASSAY ANALYZER (E170). OF THE 245 PATIENT SAMPLES, 89 HAD ERRONEOUS TEST RESULTS. THE ERRONEOUS RESULTS WERE REPORTED OUTSIDE OF THE LABORATORY TO THE DOCTOR. THE AFFECTED ASSAYS INCLUDE: THE ELECSYS AFP ASSAY (AFP), THE ELECSYS CA 19-9 IMMUNOASSAY (CA 19-9), THE ELECSYS CEA ASSAY (CEA), THE ELECSYS TOTAL PSA IMMUNOASSAY (PSA), ELECSYS FT3 III (FREE-T3), THE ELECSYS FT4 II ASSAY (FREE-T4), AND THE ELECSYS TSH ASSAY (TSH). PATIENT IDENTIFIERS FOR INFORMATION RELATED TO EACH AFFECTED ASSAY: (B)(6). PLEASE REFER TO THE ATTACHMENT FOR ALL PATIENT DATA. THE SAMPLES WERE INITIALLY TESTED ON THE CUSTOMER'S E170 ANALYZER (NAMED ELECSYS ON ATTACHMENT). THE ELECSYS VALUES HIGHLIGHTED IN ORANGE ARE ERRONEOUS. THE SAMPLES WERE REPEATED USING THE ABBOTT ARCHITECT AND WAKO ACCURASEED METHODS. SAMPLE 31 WAS PROVIDED FOR INVESTIGATION WHERE IT WAS TESTED FOR TSH, FREE-T3, AND FREE-T4 ON A COBAS 8000 E 801 MODULE - E801 (SEE BOTTOM OF ATTACHMENT). NO ADVERSE EVENTS WERE ALLEGED TO HAVE OCCURRED WITH THE PATIENTS. THE SERIAL NUMBER OF THE CUSTOMER'S E170 ANALYZER IS (B)(4). THE SERIAL NUMBER OF THE E801 ANALYZER USED FOR INVESTIGATION WAS (B)(4).