BEUDAMED
    FDA Adverse Event Death Summary report: N

    EPOC READER

    MDR report key: 16789027 · Received April 21, 2023

    Report

    Report Number
    3002637618-2023-00022
    Event Type
    Death
    Date Received
    April 21, 2023
    Date of Event
    March 17, 2023
    Report Date
    June 27, 2023
    Manufacturer
    EPOCAL INC.
    Product Code
    CHL
    UDI-DI
    00809708016685
    PMA / PMN Number
    K200107
    Adverse Event
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CA
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL
    Health Professional
    Yes

    Narratives

    Additional Manufacturer Narrative · 0

    THE CUSTOMER HAS BEEN ASKED FOR MORE INFORMATION AND INSTRUMENT FILES TO COMPLETE INVESTIGATION. THE CAUSE OF THIS EVENT IS UNKNOWN. BELOW IS THE DEFINITION OF THE ERROR AND REMEDY MENTIONED IN DEVICE MANUAL- MESSAGE: ¿IQC FAILURE: SAMPLE DELIVERY (E49).¿ DESCRIPTION: IRREGULARITIES WERE DETECTED WITH SAMPLE INJECTION. TEST FAILS. RESPONSE: REMOVE TEST CARD AND INSERT NEW TEST CARD TO BEGIN ANOTHER TEST. ENSURE THAT SYRINGE OR CAPILLARY TUBE MAKES PROPER SEAL WITH TEST CARD AND INJECT IN A SMOOTH, STEADY MOTION. AVOID INJECTING AIR INTO TEST CARD.

    Additional Manufacturer Narrative · 0

    SIEMENS HAS COMPLETED THE INVESTIGATION. A REVIEW OF THE CUSTOMER AND INTERNAL TEST DATA FOR CARD LOT 11-22329-50, AS WELL AS A REVIEW OF THE PRODUCT SPECIFICATION WAS PERFORMED. THE INVESTIGATION IDENTIFIED A DEFECT IN THE SYSTEM SOFTWARE THAT IS NOT IN-LINE WITH THE TEST CARD AND SYSTEM PERFORMANCE FOR BICARBONATE, CHCO3, AS DESCRIBED IN THE SYSTEM MANUAL. BICARBONATE IS A CALCULATED PARAMETER, MEASURED FROM PCO2 AND PH. THE REPORTABLE RANGE FOR BICARBONATE IS 1 - 85MM. .THIS MEANS THAT THE SYSTEM SHOULD BE ABLE TO REPORT OUT CHCO3 RESULTS UP TO 85MM (IN THE ABSENCE OF ANY OTHER ERROR MESSAGES) AND ANY RESULT OVER 85MM WILL BE SUPPRESSED AND DISPLAY ¿OVER REPORTABLE RANGE¿. THE IQC ERROR LIMIT FOR CHCO3 IN THE SOFTWARE IS 75MM, WHICH IS NOT IN-LINE WITH THE REPORTING RANGE OF 1-85MM. IQC LIMITS CAN BE EQUAL TO OR GREATER THAN THE UPPER LIMIT OF THE REPORTING RANGE. THE IQC ERROR IS INTENDED TO SUPPRESS RESULTS WHEN THERE IS A SUSPECTED USER ERROR OR IF SAMPLE INTEGRITY AND ACCURACY CANNOT BE GUARANTEED. BECAUSE THE IQC LIMIT AND REPORTING RANGE FOR CHCO3 OVERLAP, RESULTS BETWEEN 75 AND 85MM HAVE BEEN FALSELY SUPPRESSED (IN THE ABSENCE OF ANY OTHER ERROR MESSAGES). IT SHOULD BE NOTED THAT THE SAMPLE INTEGRITY COULD NOT BE VERIFIED AND SOME PRE-ANALYTICAL ERRORS SPECIFIC TO THIS CASE COULD NOT BE RULED OUT. THIS ISSUE IS CLASSIFIED AS A SOFTWARE DEFECT, THEREFORE, INTERNAL MEASURES ARE BEING TAKEN TO FURTHER INVESTIGATE ROOT CAUSE, RESOLVE, AND ASSESS FOR FIELD ACTION IF REQUIRED. IF A FIELD ACTION IS REQUIRED, IT WILL BE FILED SEPARATELY AS NECESSARY. FOR THE SAME CUSTOMER AND DEATH OF SAME PATIENT, A SEPARATE MDR 3002637618-2023-000021 WAS FILED FOR ANOTHER EPOC DEVICE.

    Description of Event or Problem · 0

    CUSTOMER IS ALLEGING RECEIVING SAMPLING ERROR MESSAGE ON ONE PATIENT ON (B)(6) 2023 ON SIEMENS EPOC DEVICE SN (B)(6). SIEMENS WAS MADE AWARE ON MARCH-24-2023. SIEMENS WAS INFORMED ON APR-18-2023 THAT THE PATIENT REFERENCED IN THIS COMPLAINT HAD PASSED AWAY. PLEASE SEE MDR#3002637618-2023-000021 FOR SIEMENS EPOC DEVICE SN (B)(6) BY SAME CUSTOMER RECEIVING SAME SAMPLING ERROR ON SAME PATIENT ON SAME DAY.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    865289 EPOC READER ELECTRODE MEASUREMENT, BLOOD-GASES (PCO2, PO2) AND BLOOD PH CHL EPOCAL INC. HR-1002-00-00 00809708016685

    Patients

    Seq Age Sex Outcome Treatment
    1 Unknown Death