inforMED
MalfunctionJFP

ROCHE 9180 ELECTROLYTE ANALYZER

Received Oct 17, 2018 · Event occurred Sep 28, 2018

Report 1823260-2018-03711 · MDR key 7973214

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

Description of Event or Problem

THE CUSTOMER RECEIVED QUESTIONABLE CALCIUM RESULTS FROM THE ELECTROLYTE ANALYZER 9180 THAT WOULD BE 10X THE NORMAL RESULT. ONE EXAMPLE WAS PROVIDED. THE RESULTS FOR ONE SAMPLE WERE 0.44 MMOL/L, 0.44 MMOL/L AND 4.68 MMOL/L. THE RESULT OF 0.44 MMOL/L WAS BELIEVED TO BE CORRECT. NO ERRONEOUS RESULT WAS REPORTED OUTSIDE OF THE LABORATORY. THERE WAS NO ALLEGATION OF AN ADVERSE EVENT. ALL QC RESULTS WERE IN THE ACCEPTABLE RANGE. THE CUSTOMER REPLACED ALL THE ELECTRODES, ALL TUBING, AND SNAPACK. HOWEVER, THE ISSUE WAS NOT RESOLVED. THE CUSTOMER THEN CHANGED THE CALCIUM ELECTRODE AND RAN A 20 SPECIMEN VALIDATION.

Additional Manufacturer Narrative

THE CUSTOMER WAS SENT A REPLACEMENT INSTRUMENT. THE MAINBOARD FROM THE AFFECTED SYSTEM WAS RETURNED TO ROCHE DIAGNOSTICS FOR FURTHER INVESTIGATION. THE ISSUE COULD NOT BE REPRODUCED. THE INVESTIGATION DID NOT IDENTIFY A PRODUCT PROBLEM. THE CAUSE OF THE EVENT COULD NOT BE DETERMINED.