BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    VENTANA PD-L1 (SP142) ASSAY

    MDR report key: 16875457 · Received May 5, 2023

    Report

    Report Number
    2028492-2023-00028
    Event Type
    Malfunction
    Date Received
    May 5, 2023
    Date of Event
    April 20, 2023
    Report Date
    May 5, 2023
    Manufacturer
    VENTANA MEDICAL SYSTEMS INC
    Product Code
    PLS
    PMA / PMN Number
    P160002
    Removal / Correction Number
    Z-0907-2023 RES#91199
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    UK
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL
    Health Professional
    Yes

    Narratives

    Additional Manufacturer Narrative · 0

    THE MATERIAL NUMBER IS NOT MARKETED OR DISTRIBUTED IN THE US. HOWEVER, ROCHE OBSERVED UNACCEPTABLE, LIGHT STAINING WITH SOME VENTANA PD-L1 (SP142) ON-MARKET LOTS, DURING INTERNAL COMPARISON STUDIES. LIGHT STAINING AFFECTS THE BORDERLINE OF POSITIVE VERSUS NEGATIVE TEST RESULTS. AN ON-GOING INVESTIGATION HAS DETERMINED THE ROOT CAUSE IS RELATED TO VARIABILITY IN THE SELECTION OF ANTIBODY CONCENTRATION IN RAW MATERIALS, AFFECTING SPECIFIC VENTANA PD-L1 (SP142) ASSAY LOTS MADE WITH THE IMPACTED RAW MATERIALS. A NOTIFICATION HAS BEEN SENT TO US CUSTOMERS INFORMING THEM OF THE ISSUE TO IMMEDIATELY DISCONTINUE THE USE OF AND DISCARD ANY REMAINING INVENTORY OF SPECIFIC IMPACTED LOTS AND INFORMING OF AN UPDATED DATE OF EXPIRATION FOR CERTAIN LOTS. INITIAL REPORTER FACILITY NAME TRUNCATED DUE TO CHARACTER LIMIT: ROYAL LONDON HOSPITAL CELLULAR PATHOLOGY 2ND FLOOR PATHOLOGY AND PHARMACY BLDG.

    Description of Event or Problem · 0

    A CUSTOMER FROM THE UNITED KINGDOM ALLEGED DISCREPANT RESULTS WITH THE VENTANA PD-L1 (SP142) ASSAY FOR 4 PATIENT SAMPLES. THE ALLEGED SAMPLES INITIALLY GENERATED NEGATIVE RESULTS WHICH WERE REPORTED TO MEDICAL PERSONNEL TREATING THE PATIENTS. THE SAMPLES WERE THEN RETESTED AND GENERATED POSITIVE RESULTS; THE RESULTS WERE SENT TO THE CLINICIANS. TO DATE, NO HARM OR INJURY IS ALLEGED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1693279 VENTANA PD-L1 (SP142) ASSAY PROGRAMMED DEATH-LIGAND 1 (PD-L1) IVD, ANTIBODY PLS VENTANA MEDICAL SYSTEMS INC NA G16831,G24564

    Patients

    Seq Age Sex Outcome Treatment
    1 Unknown