BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    BD MAX¿ ENTERIC BACTERIAL PANEL

    MDR report key: 17914004 · Received October 11, 2023

    Report

    Report Number
    1119779-2023-01080
    Event Type
    Malfunction
    Date Received
    October 11, 2023
    Date of Event
    September 6, 2023
    Report Date
    October 26, 2023
    Manufacturer
    BECTON DICKINSON & CO. (SPARKS)
    Product Code
    PCI
    UDI-DI
    00382904429638
    PMA / PMN Number
    K140111
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    AU
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL
    Health Professional
    Yes

    Narratives

    Additional Manufacturer Narrative · 0

    H3. INVESTIGATION SUMMARY: THE COMPLAINT INVESTIGATION FOR DISCREPANT RESULTS WHEN USING THE BD MAX¿ ENTERIC BACTERIAL PANEL ASSAY (REF. 442963) FROM LOTS: 3081374 WAS PERFORMED BY THE REVIEW OF THE MANUFACTURING RECORDS, REVIEW OF CUSTOMER¿S DATA AND BY THE COMPLAINT¿S HISTORY REVIEW. REVIEW OF THE MANUFACTURING RECORDS OF BD MAX¿ ENTERIC BACTERIAL PANEL ASSAY INDICATED THAT LOT: 3081374 WAS MANUFACTURED ACCORDING TO SPECIFICATIONS AND MET PERFORMANCE REQUIREMENTS. CUSTOMER COMPLAINED ABOUT SALMONELLA POSITIVE RESULTS ON TWO PATIENT SAMPLES WHICH WERE LATER NEGATIVE IN CULTURE AND IN THE REPEAT TEST. CUSTOMER PROVIDED DATABASES FROM INSTRUMENTS CT2207 AND CT1211 FOR INVESTIGATION. ADDITIONAL INFORMATION REVEALED THAT RUNS 519 AND 524 FROM CT2207 AND 2578 FROM CT1211 ARE THE SPECIFIC RUNS INVOLVED IN THE ISSUE. MANUAL PCR CURVE ADJUDICATION OF THE SALMONELLA POSITIVE SAMPLES (RUN 519, POSITIONS A2 AND A3) REVEALED LATE AND LOW, BUT TRUE AMPLIFICATION, WITHOUT ANOMALY INDICATIVE OF TRUE LOW POSITIVE RESULTS. AFTER THE INITIAL RUN, NEW SAMPLE BUFFER TUBES WERE PREPARED AND TESTED IN RUNS 524 AND 2578 AND GAVE SALMONELLA NEGATIVE RESULTS. CURVES ANALYSIS OF THE REPEAT TESTS DID NOT SHOW ANY ANOMALY, SUGGESTING TRUE NEGATIVE RESULTS. LOW POSITIVE SAMPLES SUCH AS THOSE OBTAINED IN THE INITIAL TEST CAN OCCUR DUE TO CONCENTRATION IN THE SPECIMEN BEING AT OR NEAR THE LIMIT OF DETECTION OF THE ASSAY OR THROUGH ENVIRONMENTAL OR CROSS CONTAMINATION INTRODUCED DURING THE SAMPLE PREPARATION AT THE CUSTOMER¿S SITE. MOREOVER, LIMIT OF DETECTION CAN VARY BETWEEN DIFFERENT ASSAYS. NEVERTHELESS, MANUAL CURVE ADJUDICATION HAS LIMITATIONS; VISUAL EXAMINATION OF PCR CURVES FOR LOW SIGNAL IS A CONSERVATIVE ASSESSMENT OF THE DATA. BD WAS UNABLE TO IDENTIFY THE EXACT CAUSE OF THE CUSTOMER¿S DISCREPANT RESULTS. NONETHELESS, NO REAGENTS ISSUE IS SUSPECTED. THE ROOT CAUSE WAS NOT IDENTIFIED. THERE IS NO INDICATION OF A REAGENT ISSUE BASED ON THE ANALYSIS OF THE COMPLAINTS RECEIVED FOR DISCREPANT RESULTS ON THE BD MAX¿ ENTERIC BACTERIAL PANEL ASSAY LOT: 3081374. BD CANNOT CONFIRM THE COMPLAINT BASED ON THE INVESTIGATION THAT WAS PERFORMED. BD DID NOT INITIATE A CORRECTIVE AND PREVENTIVE ACTION (CAPA) SINCE NO NEW HAZARD WAS IDENTIFIED. BD QUALITY WILL CONTINUE TO MONITOR FOR TRENDS.

    Additional Manufacturer Narrative · 0

    H.3. A DEVICE EVALUATION IS ANTICIPATED, BUT HAS NOT YET BEGUN. UPON COMPLETION OF THE INVESTIGATION, A SUPPLEMENTAL REPORT WILL BE FILED.

    Description of Event or Problem · 0

    REPORT 1 OF 2. IT WAS REPORTED THAT WHILE USING BD MAX¿ ENTERIC BACTERIAL PANEL THAT THERE WAS 2 FALSE POSITIVES. THE FOLLOWING INFORMATION WAS PROVIDED BY THE INITIAL REPORTER: ON (B)(4) 2023, 2 SAMPLES OF PATIENTS WITH ACUTE GASTROENTERITIS WERE MEASURED POSITIVE ON THE BD MAX CT2207. BOTH SAMPLES HAD A GOOD AMPLIFICATION AND ABOUT 2000 RFUS. THE SAME SAMPLES WERE THEN TESTED ON (B)(6) AND THEY WERE NEGATIVE AND THERE WAS NO SIGN OF AMPLIFICATION.

    Description of Event or Problem · 0

    REPORT 1 OF 2. IT WAS REPORTED THAT WHILE USING BD MAX¿ ENTERIC BACTERIAL PANEL THAT THERE WAS 2 FALSE POSITIVES. THE FOLLOWING INFORMATION WAS PROVIDED BY THE INITIAL REPORTER: ON (B)(6) 2023, 2 SAMPLES OF PATIENTS WITH ACUTE GASTROENTERITIS WERE MEASURED POSITIVE ON THE BD MAX CT2207. BOTH SAMPLES HAD A GOOD AMPLIFICATION AND ABOUT 2000 RFUS. THE SAME SAMPLES WERE THEN TESTED ON THE 08TH OF SEPTEMBER AND THEY WERE NEGATIVE AND THERE WAS NO SIGN OF AMPLIFICATION.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    2238234 BD MAX¿ ENTERIC BACTERIAL PANEL GASTROINTESTINAL BACTERIAL PANEL MULTIPLEX NUCLEIC ACID-BASED ASSAY SYSTEM PCI BECTON DICKINSON & CO. (SPARKS) 3081374 00382904429638

    Patients

    Seq Age Sex Outcome Treatment
    1 Unknown