ALINITY I TACROLIMUS REAGENT KIT
Report
- Report Number
- 1415939-2024-00011
- Event Type
- Injury
- Date Received
- March 1, 2024
- Date of Event
- February 8, 2024
- Report Date
- April 11, 2024
- Manufacturer
- ABBOTT LABORATORIES
- Product Code
- MLM
- UDI-DI
- 00380740154516
- PMA / PMN Number
- K070820
- Adverse Event
- Yes
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- SP
- Reporter Occupation
- OTHER HEALTH CARE PROFESSIONAL
- Health Professional
- Yes
Narratives
SECTION A1 - PATIENT IDENTIFIER: SIDS (B)(6). AN EVALUATION IS IN PROCESS. A FOLLOW-UP REPORT WILL BE SUBMITTED WHEN THE EVALUATION IS COMPLETE.
SECTION B5 - DESCRIBE EVENT OR PROBLEM: THIS SECTION WAS UPDATED WITH ADDITIONAL INFORMATION PROVIDED BY THE CUSTOMER ON 07MAR2024. AN EVALUATION IS IN PROCESS. A FOLLOW-UP REPORT WILL BE SUBMITTED WHEN THE EVALUATION IS COMPLETE.
THE COMPLAINT INVESTIGATION FOR FALSELY ELEVATED ALINITY I TACROLIMUS RESULT INCLUDED A REVIEW OF DATA AND INFORMATION PROVIDED BY THE CUSTOMER, SEARCH FOR SIMILAR COMPLAINTS, TICKET TRENDING REVIEW, DEVICE HISTORY RECORD REVIEW, AND LABELING REVIEW. IN ADDITION, IN-HOUSE TESTING OF RETAINED REAGENT KIT WAS ALSO COMPLETED. RETURN TESTING WAS NOT COMPLETED AS RETURNS WERE NOT AVAILABLE. THE DATA AND INFORMATION PROVIDED BY THE CUSTOMER WERE REVIEWED AND SUPPORT THE COMPLAINT ISSUE. A TICKET SEARCH BY LOT INDICATES THE REAGENT LOT IS PERFORMING AS EXPECTED FOR THIS PRODUCT. A REVIEW OF THE COMPLAINT TRENDING REPORT DID NOT IDENTIFY ANY TRENDS FOR THE ISSUE FOR THE PRODUCT. A REVIEW OF THE DEVICE HISTORY RECORD DID NOT IDENTIFY ANY NON-CONFORMANCES OR DEVIATIONS WITH LOT 56743FP00 AND COMPLAINT ISSUE. AN ACCURACY TESTING WAS COMPLETED USING AN IN-HOUSE RETAINED REAGENT KIT OF LOT 56743FP00 STORED AT THE RECOMMENDED STORAGE CONDITION. THE TESTING MEETS ALL VALIDITY AND ACCEPTANCE CRITERIA. A REVIEW OF LABELING WAS PERFORMED AND FOUND TO SUFFICIENTLY ADDRESS THE CUSTOMER'S ISSUE. BASED ON THE REVIEW OF THIS ISSUE, USE ERROR MAY HAVE CONTRIBUTED TO THE CUSTOMERS ISSUE AS THE COMPLAINT NOTES INDICATE THE PREPROCESSING (PIPETTES, TIPS, ETC.) ARE QUITE OLD AND ADDED TO TECHNICIAN INEXPERIENCE, COULD HAVE CAUSED THESE DISCREPANCIES. BASED ON THIS INVESTIGATION, NO SYSTEMIC ISSUE OR DEFICIENCY WAS IDENTIFIED FOR THE ALINITY I TACROLIMUS REAGENT LOT 56743FP00.
THE CUSTOMER REPORTED FALSELY ELEVATED ALINITY I TACROLIMUS RESULT GENERATED ON THE ALINITY I PROCESSING MODULE FOR A PATIENT. THE RESULT WAS RELEASED OUT OF THE LAB. THE FOLLOWING DATA WAS PROVIDED: PATIENT 2: ON (B)(6) 2024, SID (B)(6) , RESULT = 18.3 NG/ML. ON (B)(6) 2024 ,SID (B)(6) , RESULT = 9.1 NG/ML. THE CUSTOMER STATED THAT DUE TO THE FALSELY ELEVATED ALINITY I TACROLIMUS RESULT, UNNECESSARY BIOPSY WAS PERFORMED ON THE PATIENT. ADDITIONAL INFORMATION REGARDING THE BIOPSY WAS REQUESTED; HOWEVER, TO DATE, IT HAS NOT BEEN PROVIDED AND/OR RECEIVED. THERE WAS NO FURTHER IMPACT TO PATIENT MANAGEMENT REPORTED.
UPDATE: ON 07MAR2024, THE CUSTOMER PROVIDED ADDITIONAL INFORMATION. THE SAMPLES WERE FROM A POST KIDNEY TRANSPLANT PATIENT AND THE BLOOD DRAW WAS TAKEN 24 HOURS AFTER THE MEDICATION WAS GIVEN. IT WAS NOTED THAT BOTH RESULTS WERE FROM THE SAME BLOOD DRAW. THERE WAS NO FURTHER IMPACT TO PATIENT MANAGEMENT REPORTED.
THE CUSTOMER REPORTED FALSELY ELEVATED ALINITY I TACROLIMUS RESULT GENERATED ON THE ALINITY I PROCESSING MODULE FOR A PATIENT. THE RESULT WAS RELEASED OUT OF THE LAB. THE FOLLOWING DATA WAS PROVIDED: PATIENT 2: (B)(6) 2024 SID (B)(6) RESULT = 18.3 NG/ML. (B)(6) 2024 SID (B)(6) RESULT = 9.1 NG/ML. THE CUSTOMER STATED THAT DUE TO THE FALSELY ELEVATED ALINITY I TACROLIMUS RESULT, UNNECESSARY BIOPSY WAS PERFORMED ON THE PATIENT. ADDITIONAL INFORMATION REGARDING THE BIOPSY WAS REQUESTED; HOWEVER, TO DATE, IT HAS NOT BEEN PROVIDED AND/OR RECEIVED. THERE WAS NO FURTHER IMPACT TO PATIENT MANAGEMENT REPORTED. UPDATE: ON 07MAR2024, THE CUSTOMER PROVIDED ADDITIONAL INFORMATION. THE SAMPLES WERE FROM A POST KIDNEY TRANSPLANT PATIENT AND THE BLOOD DRAW WAS TAKEN 24 HOURS AFTER THE MEDICATION WAS GIVEN. IT WAS NOTED THAT BOTH RESULTS WERE FROM THE SAME BLOOD DRAW. THERE WAS NO FURTHER IMPACT TO PATIENT MANAGEMENT REPORTED.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 2002193 | ALINITY I TACROLIMUS REAGENT KIT | ENZYME IMMUNOASSAY, TRACROLIMUS | MLM | ABBOTT LABORATORIES | 56743FP00 | 00380740154516 |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | NA | Unknown | Disability | ALNTY I PROCESSING MODU, 03R65-01, (B)(6)| ALNTY I PROCESSING MODU, 03R65-01, (B)(6)| ALNTY I PROCESSING MODU, 03R65-01, (B)(6) |