BEUDAMED
    FDA Adverse Event Injury Summary report: N

    ACCESS VITAMIN B12 COBALAMIN

    MDR report key: 11573725 · Received March 26, 2021

    Report

    Report Number
    2122870-2021-00040
    Event Type
    Injury
    Date Received
    March 26, 2021
    Date of Event
    February 24, 2020
    Report Date
    March 26, 2021
    Manufacturer
    BECKMAN COULTER
    Product Code
    CDD
    UDI-DI
    15099590224301
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    AS
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL

    Narratives

    Additional Manufacturer Narrative · 1

    THE FULL PATIENT IDENTIFIER IS (B)(6). (NUMBER OF PATIENTS NOT SPECIFIED). THE CUSTOMER DID NOT SUPPLY PATIENT DEMOGRAPHICS SUCH AS AGE, DATE OF BIRTH, SEX, WEIGHT, ETHNICITY OR RACE. THE VITAMIN B12 (ACCESS VITAMIN B12 COBALAMIN) REAGENTS WERE NOT RETURNED FOR EVALUATION. ALL OF THE SYSTEM PARAMETERS, INCLUDING QC, CALIBRATIONS AND SYSTEM CHECKS WERE PERFORMING WITHIN ASSAY AND INSTRUMENT SPECIFICATIONS. THERE WERE NO HARDWARE ERRORS OR OTHER FLAGS REPORTED AT THE TIME OF THE EVENT. THE VITAMIN B12 ASSAY HAS NO WORLDWIDE STANDARDIZATION. EACH MANUFACTURER TRACES THEMSELVES BACK TO THEIR OWN WORKING MATERIAL, WHICH MAY CREATE DIFFERENCES IN RESULTS BETWEEN MANUFACTURERS. HOWEVER, THE CLINICAL SIGNIFICATION SHOULD REMAIN THE SAME. INDEED, THE NORMAL REFERENCE RANGE ARE DIFFERENT DEPENDING ON THE METHOD USED. ADDITIONAL AND PER THE VITAMIN B12 INSTRUCTIONS FOR USE, ¿EACH LABORATORY SHOULD ESTABLISH ITS OWN REFERENCE RANGES TO ASSURE PROPER REPRESENTATION OF SPECIFIC POPULATIONS.¿ IN CONCLUSION, THE CAUSE OF THIS EVENT CANNOT BE DETERMINED WITH THE AVAILABLE INFORMATION. THERE IS NO EVIDENCE TO REASONABLY SUGGEST THAT A MALFUNCTION OCCURRED IN CONJUNCTION WITH THIS EVENT.

    Description of Event or Problem · 1

    ON (B)(6) 2021 THE CUSTOMER REPORTED LOW VITAMIN B12 (ACCESS VITAMIN B12 COBALAMIN ¿ PART NUMBER 33000) PATIENT RESULTS IN COMPARISON WITH OTHER METHODS, OBTAINED ON DXI 800 ACCESS IMMUNO ASSAY W/SPOT B ANALYZERS. THE CUSTOMER USES NORMAL REFERENCE RANGES STATED IN THE VITAMINB12 INSTRUCTIONS FOR USE (IFU): 133 - 675 PMOL/L (180 - 914 PG/ML). CLINICIANS USE 148 PMOL/L (200 PG/ML) AS A CUT-OFF FOR POSSIBLE VITAMIN B12 DEFICIENCY REQUIRING FURTHER INVESTIGATION INSTEAD OF A REFERENCE INTERVAL. THE CUSTOMER REPORTED THAT AFTER THE INTRODUCTION OF THE ACCESS VITAMIN B12 ASSAY ON (B)(6) 2020, APPROXIMATELY 22% OF VITAMIN B12 RESULTS REPORTED HAVE BEEN < 150 PMOL/L. IN COMPARISON, USING THE ROCHE METHOD (PREVIOUS METHOD), ONLY 3.5% WERE BELOW THIS CUT-OFF. THE CUSTOMER REPORTED A CLINICAL PROBLEM BECAUSE THE DOCTORS ARE FINDING IT HARD TO UNDERSTAND THESE RESULTS AND TREAT PATIENTS CORRECTLY BASED ON THEM. THE CUSTOMER SUGGESTED THAT UNNECESSARY PRESCRIPTIONS WERE MADE AND THAT VITAMIN B12 PRESCRIPTIONS DOUBLED AFTER THE INTRODUCTION OF THE ACCESS ASSAY ((B)(6) 2020). NO DETAIL REGARDING THE TYPE OF PRESCRIPTION WAS PROVIDED (OVER THE COUNTER B12 OR INJECTIONS). NO FURTHER CHANGE IN TREATMENT WAS REPORTED. NO FURTHER INFORMATION WAS PROVIDED. THERE WERE NO HARDWARE ERRORS OR OTHER FLAGS REPORTED AT THE TIME OF THE EVENT. ARCHIVE DATA FILES (.CSV FILE) WERE ANALYZED. IT SHOWED DATA OBTAINED BETWEEN 1MAR2021 AND 15MAR2021 ON THEIR LABORATORY¿S DXI ANALYZERS (SERIAL NUMBER (SN) (B)(4)). ANALYSIS OF THIS FILE DID NOT HIGHLIGHT ANY SPECIFIC ISSUE WITH CUSTOMER¿S ANALYZER. ALL OF THE SYSTEM PARAMETERS, INCLUDING QC, CALIBRATIONS AND SYSTEM CHECKS WERE PERFORMING WITHIN ASSAY AND INSTRUMENT SPECIFICATIONS. IT SHOWED THAT OVER THE 793 VITAMIN B12 RESULTS, 224 WERE LOWER THAN 148 PMOL/L, I.E. 22%. NO ISSUES WITH SAMPLE INTEGRITY WERE REPORTED BY THE CUSTOMER. NO SAMPLE COLLECTION OR PROCESSING INFORMATION WAS PROVIDED BY THE CUSTOMER.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    471903 ACCESS VITAMIN B12 COBALAMIN RADIOASSAY, VITAMIN B12 CDD BECKMAN COULTER 33000 922779 15099590224301

    Patients

    Seq Age Sex Outcome Treatment
    1 Other