BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    LUMIRADX SARS-COV-2 AG TEST STRIP KIT

    MDR report key: 12255818 · Received July 30, 2021

    Report

    Report Number
    3012642695-2021-01270
    Event Type
    Malfunction
    Date Received
    July 30, 2021
    Date of Event
    July 5, 2021
    Report Date
    July 30, 2021
    Manufacturer
    LUMIRADX UK LTD.
    Product Code
    QKP
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    AU
    Reporter Occupation
    PHYSICIAN

    Narratives

    Additional Manufacturer Narrative · 1

    PATIENT WAS REPORTED TO BE SYMPTOMATIC ("PATIENT HAD A COLD") WHEN INITIAL LUMIRADX SARS-COV-2 AG TEST WAS PERFORMED ON (B)(6) 2021 WITH STRIP LOT 6000256 AND INSTRUMENT SERIAL NUMBER (B)(4). SECONDARY TESTING WAS PERFORMED ON AN ALTERNATIVE INSTRUMENT OF ANOTHER MANUFACTURER'S MAKE AND MODEL (AEGLE CORONAVIRUS AG RAPID TEST) WHICH PRODUCED A NEGATIVE RESULT. THE CUSTOMER REPORTED THE FOLLOWING PROCESS FOR TESTING ON THE LUMIRADX PLATFORM: "SAMPLE IS TAKEN AND MEASURED DIRECTLY." THE CUSTOMER REPORTED THEIR CLEANING PRACTICES TO BE "STRIPS ARE REMOVED DIRECTLY AND THE INSTRUMENT IS WIPED WITH A DRY CLOTH", AND FURTHER REPORTED THAT GLOVES ARE CHANGED AFTER EACH SAMPLE. LOT 6000256 MET ALL DEFINED QC CRITERIA AT THE TIME IT WAS RELEASED AND TESTING USING NEGATIVE NASAL SWABS FROM IN-HOUSE DONORS MEETS EXPECTED PERFORMANCE FOR USE IN THE FIELD. REVIEW OF PRODUCT RISK ASSESSMENT - SARS-COV-2 AG ASSAY REVISION 7, RESULTED IN SEVERITY OF MODERATE, AS FOLLOWS: DELAYED DIAGNOSIS LEADING TO DELAYED TREATMENT OF THE TRUE CAUSE OF THE PATIENT'S SYMPTOMS. UNNECESSARY ISOLATION. NO PATIENT HARM, INJURY OR ADVERSE HEALTH CONSEQUENCES WERE COMMUNICATED BY THE CUSTOMER TO LUMIRADX FOR THE REPORTED DISCORDANT RESULT. TRENDING DATA FOR DISCORDANT RESULTS WAS REVIEWED FOR THIS LOT AND THE OCCURRENCE RATE PER QUANTITY OF STRIPS IN THE FIELD WAS CALCULATED AS (B)(4). LUMIRADX SARS-COV-2 AG TEST PRODUCT INSERT CLAIMS A SPECIFICITY OF 96.6% WITH A REFERENCE RT-PCR ASSAY AND IT IS ACCEPTED THAT UP TO 3.4% OF TEST STRIPS MAY GENERATE A DISCORDANT FALSE POSITIVE RESULT. LUMIRADX R&D REVIEW OF COMPLAINT DATA IDENTIFIED THAT AEGLE CORONAVIRUS AG RAPID TEST IS A LATERAL FLOW TEST, WITH A LOWER SENSITIVITY THAN THE LUMIRADX SARS-COV-2 AG TEST - AEGLE LOD IS APPROXIMATELY 4-FOLD LOWER (115 TCID50/ML VS 32 TCID50/ML), THAN LUMIRADX; THEREFORE THE SIMILARITY IN CLINICAL AGREEMENT MOST LIKELY COMES FROM AEGLE SAMPLE SET CONTAINING A HIGHER VIRAL LOAD. THE REDUCED SENSITIVITY AND DIFFERENCES IN LOD, SPECIFICALLY AT LOW VIRAL TITERS, SUGGESTS THAT IT IS ENTIRELY POSSIBLE THESE RESULTS REPRESENT A TRUE POSITIVE FROM LUMIRADX TEST AND A FALSE NEGATIVE FROM THE AEGLE TEST. ROOT CAUSE DETERMINATION: NO DEFINITIVE ROOT CAUSE HAS BEEN DETERMINED FOR THE REPORTED DISCORDANT RESULT BASED ON THE INFORMATION CURRENTLY AVAILABLE. INVESTIGATION CONCLUSION AND STATUS OF INVESTIGATION: NO FURTHER INVESTIGATION IS CONSIDERED NECESSARY AT THIS TIME. THIS STRIP LOT CONTINUES TO DEMONSTRATE FIELD PERFORMANCE WITHIN SPECIFICATION OF PRODUCT CLAIMS RELATIVE TO THE QUANTITY OF STRIPS FROM THIS LOT IN THE FIELD. REPORTS OF DISCORDANT RESULTS FOR THIS LOT WILL CONTINUE TO BE TRENDED AND REVIEWED, WITH ACTION TAKEN AS APPROPRIATE IN RESPONSE TO ANY ADVERSE TRENDS OR EVENTS INCLUDING A FOLLOW-UP REPORT.

    Description of Event or Problem · 1

    THIS IS REPORT 2 OF 3 FOR THIS FACILITY AND AWARE DATE. THE CUSTOMER REPORTED A SUSPECTED FALSE (INCORRECT) POSITIVE RESULT FROM A RAPID RESULT COVID TEST SYSTEM ON AN INDIVIDUAL SYMPTOMATIC PATIENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1148855 LUMIRADX SARS-COV-2 AG TEST STRIP KIT CORONAVIRUS ANTIGEN DETECTION TEST SYSTEM QKP LUMIRADX UK LTD. 6000256

    Patients

    Seq Age Sex Outcome Treatment
    1