inforMED
MalfunctionJFP

STAT PROFILE PRIME PLUS ANALYZER SYSTEM

Received Sep 4, 2019 · Event occurred Aug 4, 2019

Report 1219029-2019-00045 · MDR key 8959569

Device

Generic name

Blood Gas Analyzer

Model number

57400

Product problems

  • Incorrect Measurement
  • Incorrect, Inadequate or Imprecise Result or Readings
  • Incorrect Measurement

Patient

Not reported

  • No Known Impact Or Consequence To Patient
  • No Known Impact Or Consequence To Patient

Narrative

Additional Manufacturer Narrative

DEVICE INVESTIGATION: A NOVA BIOMEDICAL TECHNICIAN PERFORMED A FIELD SERVICE SUPPORT FOLLOW-UP VISIT TO THE USER FACILITY, AND DURING INSPECTION OF THE ANALYZER, THE TECHNICIAN FOUND THAT THE SAMPLE PROBE S-LINE WAS KINKED. THE TECHNICIAN REPLACED THE SAMPLER ASSEMBLY TO CORRECT THE ISSUE. UPON EXAMINATION OF THE RETURNED S-LINE TO THE MANUFACTURER, A BREAK WAS OBSERVED IN THE KINKED SECTION OF THE S-LINE. THIS BREAK WOULD PREVENT FLOW, CAUSE ERRORS, AND THE ANALYZER WOULD NOT CALIBRATE. THEREFORE, IT IS HIGHLY UNLIKELY THAT THE BREAK WAS PRESENT DURING THE TIME OF THE DISCREPANT CALCIUM RESULTS. DEVICE HISTORY REVIEWS (DHRS) WERE PERFORMED ON THE ANALYZER, S-LINE, AND REFERENCE CARTRIDGE BATCHES. NO ABNORMALITIES WERE OBSERVED, AND THE DHRS INDICATED THE RELEASED PRODUCT MET ALL SPECIFICATIONS. BASED ON THE AVAILABLE INFORMATION, THE COMPLAINT COULD NOT BE CONFIRMED.

Additional Manufacturer Narrative

INVESTIGATION IN PROCESS, NO PATIENT IMPACT WAS REPORTED. CUSTOMER WAS UNABLE TO PROVIDE ANY PATIENT ICA VALUES BUT STATED THAT QUALITY CONTROL WAS IN RANGE BEFORE AND AFTER INCIDENT OCCURED.

Description of Event or Problem

CUSTOMER REPORTED DISCREPANT IONIZED CALCIUM RESULT USING NOVA STAT PROFILE PRIME PLUS ANALYZER, SN (B)(4), WHEN COMPARED TO OTHER PRIME PLUS ANALYZER. NO ADVERSE EVENT WAS REPORTED.