inforMED
MalfunctionJFP

ROCHE 9180 ELECTROLYTE ANALYZER

Received Aug 6, 2018 · Event occurred Jul 20, 2018

Report 1823260-2018-02623 · MDR key 7752893

Device

Generic name

Electrolyte Analyzer

Manufacturer

Roche Diagnostics

Model number

ISE 9180

Catalog number

03157334001

Lot number

NA

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)(6).

Description of Event or Problem

THE CUSTOMER STATED THAT THEY RECEIVED AN ERRONEOUS RESULT FOR ONE PATIENT SAMPLE TESTED FOR POTASSIUM ON A ROCHE 9180 ELECTROLYTE ANALYZER. THE SAMPLE RESULTED WITH A POTASSIUM VALUE OF 6.7 MMOL/L WHEN TESTED ON THE 9180. THE SAMPLE WAS REPEATED ON AN ISTAT ANALYZER, RESULTING AS 4.6 MMOL/L. BOTH VALUES WERE REPORTED OUTSIDE OF THE LABORATORY TO THE DOCTOR. NO ADVERSE EVENTS WERE ALLEGED TO HAVE OCCURRED WITH THE PATIENT. THE POTASSIUM ELECTRODE LOT NUMBER AND EXPIRATION DATE WERE ASKED FOR, BUT NOT PROVIDED.

Additional Manufacturer Narrative

NO QC RESULTS OR DATA WERE PROVIDED. THE PRODUCT WAS REQUESTED FOR INVESTIGATION BUT NOT RETURNED. THE CUSTOMER CONTINUED USING THE AFFECTED ELECTRODE, AND THERE WERE NO FURTHER ISSUES. THE INVESTIGATION DID NOT IDENTIFY A PRODUCT PROBLEM. THE CAUSE OF THE EVENT COULD NOT BE DETERMINED.