inforMED
MalfunctionDHX

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 Diagnostics

Model number

NA

Catalog 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).