FDA Adverse Event Other Summary report: N

ATTELLICA ACETAMINOPHEN

MDR report key: 18826050 · Received March 1, 2024

Report

Report Number
MW5152256
Event Type
Other
Date Received
March 1, 2024
Report Date
February 29, 2024
Manufacturer
SIEMENS HEALTHCARE DIAGNOSTICS INC.
Product Code
LDP
Report Source
Voluntary report
Reporter Location
IL, US
Reporter Occupation
OTHER HEALTH CARE PROFESSIONAL
Health Professional
*

Narratives

Description of Event or Problem · 0

I AM THE MEDICAL DIRECTOR OF THE (B)(6) AND WOULD LIKE TO REPORT AN ISSUE WITH ACETAMINOPHEN UNITS REPORTED BY THE SIEMEN¿S ATTELLICA ANALYZER. THE DEFAULT REPORTING UNITS FOR ACETAMINOPHEN CONCENTRATION REPORTED BY THE ANALYZER IS MG/DL. THE TREATMENT DECISION TOOL FOR ACUTE ACETAMINOPHEN OVERDOSES IS THE RUMACK-MATTHEW NOMOGRAM AND IT USES MCG/ML FOR THE UNITS. HTTPS://EMEDICINE.MEDSCAPE.COM/ARTICLE/820200-WORKUP#C8. HAVING NON-STANDARD UNITS AS THE DEFAULT UNITS CREATES A SYSTEMIC ERROR WHERE PATIENTS CAN BE INJURED BECAUSE UNITS REPORTED IN MG/DL WILL NOT MATCH UP WITH THE UNITS IN THE TREATMENT DECISION TOOL. TO DATE, I AM AWARE OF 5 HOSPITALS IN (B)(6) WITH THIS ISSUE IN THE PAST 12-16 MONTHS ¿ 3 OF THE HOSPITALS HAVE ADJUSTED THE INTERFACE TO THE EMR SO THAT REPORTING IS NOW IN STANDARD UNITS. I NOTIFIED THE SIEMENS REPRESENTATIVE FOR THE REGION LAST YEAR OF THIS PATIENT QUALITY ISSUE, BUT SINCE THEN 3 ADDITIONAL HOSPITALS IMPLEMENTED THE ANALYZER WITH THE NON-STANDARD DEFAULT UNITS. IS IT POSSIBLE THAT THE FDA CAN REQUIRE SIEMENS TO REPORT ACETAMINOPHEN CONCENTRATIONS IN THE SAME UNITS AS THE TREATMENT DECISION TOOL? REPORTING ACETAMINOPHEN CONCENTRATION IN MCG/ML IS THE US AND GLOBAL STANDARD. I AM AWARE OF ONE LIVER INJURY TO DATE IN IL DUE TO TREATMENT ERROR CREATED BY THE DEFAULT REPORTING UNITS USED BY THE SIEMENS ATELLICA ANALYZER.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1881876 ATTELLICA ACETAMINOPHEN COLORIMETRY, ACETAMINOPHEN LDP SIEMENS HEALTHCARE DIAGNOSTICS INC.

Patients

Seq Age Sex Outcome Treatment
1 NA Unknown