Description of Event or Problem · 1
THE USER RECEIVED QUESTIONABLE CALCIUM RESULTS FOR NINE PATIENT SAMPLES FROM INTEGRA 800 SERIAL NUMBER (B)(4). ALL RESULTS ARE IN MG/DL. PATIENT SAMPLE 1 INITIAL RESULT WAS 10.3 AND THE REPEAT RESULT WAS 9.2. PATIENT SAMPLE 2 INITIAL RESULT WAS 10.0 AND THE REPEAT RESULT WAS 8.9. PATIENT SAMPLE 3 INITIAL RESULT WAS 12.4 AND THE REPEAT RESULT WAS 9.8. PATIENT SAMPLE 4 INITIAL RESULT WAS 12.6 AND THE REPEAT RESULT WAS 9.6. PATIENT SAMPLE 5 INITIAL RESULT WAS 12.1 AND THE REPEAT RESULT WAS 10.1. PATIENT SAMPLE 6 INITIAL RESULT WAS 10.4 AND THE REPEAT RESULT WAS 8.5. PATIENT SAMPLE 7 INITIAL RESULT WAS 12.5 AND THE REPEAT RESULT WAS 9.1. PATIENT SAMPLE 8 INITIAL RESULT WAS 11.2 AND THE REPEAT RESULT WAS 9.0. PATIENT SAMPLE 9 INITIAL RESULT WAS 10.6 AND THE REPEAT RESULT WAS 9.0. THE INITIAL RESULTS WERE REPORTED OUTSIDE THE LABORATORY. THE USER DID NOT HAVE INFORMATION CONCERNING IF THE PATIENTS WERE ADVERSELY AFFECTED. THE FIELD SERVICE REPRESENTATIVE DETERMINED THERE WAS A DEFECTIVE LOT OF CALCIUM REAGENT AND REPLACED THE REAGENT. HE VERIFIED THE ANALYZER OPERATION BY SUCCESSFULLY RETURNING THE QUALITY CONTROL LEVELS TO NORMAL. INTERNAL INVESTIGATIONS REVEALED THE PRESENCE OF PRECIPITATE IN REAGENT 2 (R2) OF THE CALCIUM REAGENT LOT. THE ROOT CAUSE FOR THE PRECIPITATION IS STILL UNDER INVESTIGATION. AN URGENT MEDICAL DEVICE REMOVAL NOTICE WAS MAILED OCTOBER 13, 2010 TO ALL CUSTOMERS TO IMMEDIATELY DISCONTINUE USE OF THE CALCIUM REAGENT LOT. CALCIUM DEVIATIONS OF > 20% ABOVE AND BELOW THE REFERENCE RANGE ARE CONSIDERED CRITICAL. THESE DEVIATIONS COULD LEAD TO NON-DETECTION OF A PATHOLOGICAL STATUS OR MAY LEAD TO UNNECESSARY THERAPEUTIC CONSEQUENCES. THE ERRONEOUS BIAS CAUSED BY THIS ASSAY LOT MAY CAUSE PATIENT SAMPLES WITH CRITICALLY HIGH OR CRITICALLY LOW CALCIUM LEVELS TO HAVE RESULTS THAT APPEAR TO BE IN THE NORMAL RANGE. THESE PATIENTS MAY BE AT HIGH RISK FOR MISDIAGNOSIS OF PATHOLOGICAL CONDITIONS ASSOCIATED WITH ABNORMAL CALCIUM LEVELS. INACCURATELY HIGH CALCIUM VALUES MAY LEAD TO AN INCORRECT DIAGNOSIS DEPENDING ON THE BLOOD CALCIUM LEVEL. IN THE WORST CASE, THE WRONG THERAPY MAY BE INITIATED. SUSPECTED HYPERCALCEMIA WOULD MEAN CONFIRMING THE CALCIUM VALUE QUICKLY, AND TREATMENT WOULD OCCUR ACCORDING TO THE CLINICAL PICTURE. A PATIENT NORMALLY SHOWS OBVIOUS SYMPTOMS IF THE CALCIUM VALUE IS >12 MG/DL. IN THE CASE OF INACCURATELY LOW VALUES, THE CALCIUM VALUE MUST BE INTERPRETED TOGETHER WITH OTHER PARAMETERS (E.G., MAGNESIUM, PHOSPHATE, AND PTH). UNNECESSARY FURTHER EXAMINATION AND BLOOD COLLECTION MAY RESULT.