FDA Adverse Event Malfunction Summary report: N

COBAS 6000 C501 MODULE

MDR report key: 1790257 · Received August 10, 2010

Report

Report Number
1823260-2010-04712
Event Type
Malfunction
Date Received
August 10, 2010
Date of Event
July 27, 2010
Report Date
August 10, 2010
Manufacturer
ROCHE DIAGNOSTICS
Product Code
CJY
PMA / PMN Number
K060373
Removal / Correction Number
NA
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
OH, US
Reporter Occupation
HEALTH PROFESSIONAL

Narratives

Description of Event or Problem · 1

THE USER RECEIVED QUESTIONABLE CALCIUM RESULTS FOR SIX PATIENTS. ALL REPEAT TESTING WAS PERFORMED ON A DIFFERENT COBAS 6000 C501 MODULE (THE SERIAL NUMBER IS UNKNOWN). PATIENT 1, INITIAL RESULT WAS 5.9 MG/DL (ACCOMPANIED BY A DATA FLAG). THE SAME SAMPLE REPEATED GAVE 8.7 MG/DL. PATIENT 2, FEMALE, AGE (B)(6), INITIAL RESULT WAS 5.6 MG/DL (ACCOMPANIED BY A DATA FLAG). THE SAME SAMPLE REPEATED GAVE 7.8 MG/DL (ACCOMPANIED BY A DATA FLAG). PATIENT 3, MALE, AGE (B)(6), INITIAL RESULT WAS 7.0 MG/DL (ACCOMPANIED BY A DATA FLAG). THE SAME SAMPLE REPEATED GAVE 9.7 MG/DL. PATIENT 4, MALE, AGE (B)(6), INITIAL RESULT WAS 6.8 MG/DL (ACCOMPANIED BY A DATA FLAG). THE SAME SAMPLE REPEATED GAVE 9.6 MG/DL. PATIENT 5, MALE, AGE (B)(6), INITIAL RESULT WAS 6.5 MG/DL (ACCOMPANIED BY A DATA FLAG). THE SAME SAMPLE REPEATED GAVE 9.2 MG/DL. PATIENT 6, INITIAL RESULT WAS 5.6 MG/DL (ACCOMPANIED BY A DATA FLAG). THE SAME SAMPLE REPEATED GAVE 8.4 MG/DL (ACCOMPANIED BY A DATA FLAG). ALL THE INITIAL CALCIUM RESULTS WERE REPORTED OUTSIDE THE LABORATORY. ALL THE PATIENTS, EXCEPT PATIENT 2, WERE NOT AFFECTED BY THE INITIAL CALCIUM RESULTS. PATIENT 2 WAS AN EMERGENCY ROOM PATIENT AND WAS TREATED BASED ON THE INITIAL CALCIUM RESULT. THE USER REFUSED TO PROVIDE ANY FURTHER INFORMATION REGARDING THE PATIENT OR THE TREATMENT PROVIDED. NO ADVERSE EVENTS WERE REPORTED. THE CALCIUM REAGENT LOT NUMBER WAS 62492901. THE FIELD SERVICE REPRESENTATIVE DETERMINED A DIRTY INCUBATION BATH WAS THE CAUSE OF THE DISCREPANCIES. HE PERFORMED BATH EXCHANGES AND NATURAL CYCLING OF THE WATER WHICH CLEANED THE BATH. CALIBRATIONS AND QUALITY CONTROL WERE PERFORMED BY THE USER WHICH WERE SUCCESSFUL.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 COBAS 6000 C501 MODULE CLINICAL CHEMISTRY ANALYZER CJY ROCHE DIAGNOSTICS NA NA

Patients

Seq Age Sex Outcome Treatment
1 039 YR