inforMED
MalfunctionCEO

VITROS CHEMISTRY PRODUCTS PHBR SLIDES

Received Jan 30, 2008 · Event occurred Jan 5, 2008

Report 1319809-2008-00025 · MDR key 988653

Device

Generic name

In-vitro Diagnostic

Model number

NA

Catalog number

822-1384

Lot number

2524-034-7449

Product problems

  • False Negative Result

Patient

Not reported

  • No Consequences Or Impact To Patient

Narrative

Description of Event or Problem

THE CUSTOMER CALIBRATED PHBR AND OBTAINED NEGATIVELY BIASED PHBR QC RESULTS ON THEIR VITROS 5, 1 FS CHEMISTRY SYSTEM. BIASED RESULTS OF THE DIRECTION AND MAGNITUDE OBSERVED COULD LEAD TO INAPPROPRIATE PHYSICIAN ACTION. THERE WAS NO REPORT OF PT HARM AS A RESULT OF THIS EVENT.

Additional Manufacturer Narrative

THE INVESTIGATION DETERMINED THAT THE VITROS 5,1 WAS OPERATING AS EXPECTED. THE BIASED PHBR QC RESULTS WERE DUE TO USER ERROR AS THE INCORRECT CALIBRATOR KIT WAS SELECTED WHEN PROGRAMMING THE PHBR CALIBRATION.