BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    DADE® THROMBIN REAGENT

    MDR report key: 19826720 · Received July 25, 2024

    Report

    Report Number
    9610806-2024-00021
    Event Type
    Malfunction
    Date Received
    July 25, 2024
    Date of Event
    June 20, 2024
    Report Date
    August 9, 2024
    Manufacturer
    SIEMENS HEALTHCARE DIAGNOSTICS PRODUCTS GMBH
    Product Code
    KQJ
    UDI-DI
    00842768003950
    PMA / PMN Number
    K050928
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    FI
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL
    Health Professional
    Yes

    Narratives

    Additional Manufacturer Narrative · 0

    AN OUTSIDE OF THE UNITED STATES (OUS) CUSTOMER CONTACTED THE SIEMENS CUSTOMER CARE CENTER (CCC) TO REPORT THE OBSERVATION OF FALSELY DEPRESSED FIBRINOGEN RESULTS ON ONE PATIENT MEASURED WITH THE DADE THROMBIN REAGENT ON A SYSMEX CS-5100 SYSTEM COMPARED TO THE HISTORICAL FIBRINOGEN RESULTS OBTAINED ON AN ALTERNATE METHOD. THE INSTRUMENT GENERATED A FLAG AND DID NOT DISPLAY NUMERICAL RESULTS, AND THE USER IGNORED OR MISINTERPRETED THE MESSAGE OR FLAG AND REPORTED NUMERICAL RESULTS. THE INSTRUMENT PERFORMED AS EXPECTED. PER THE LIMITATIONS SECTION OF THE DADE THROMBIN REAGENT INSTRUCTIONS FOR USE (IFU): "RESULTS OF THIS TEST SHOULD ALWAYS BE INTERPRETED IN CONJUNCTION WITH THE PATIENT'S MEDICAL HISTORY, CLINICAL PRESENTATION AND OTHER FINDINGS." SIEMENS IS INVESTIGATING.

    Additional Manufacturer Narrative · 0

    SIEMENS FILED THE INITIAL MDR 9610806-2024-00021 ON 25-JUL-2024. ADDITIONAL INFORMATION 01-AUG-2024: OVERALL SIEMENS COULD NOT IDENTIFY A CLEAR RESULT DISCORDANCE IN THE PATIENT SAMPLE RECOVERY FOR THE COMPLAINED SAMPLE USING THE SYSMEX CS-5100 SYSTEM WITH DADE THROMBIN REAGENT. THE DISCORDANT RESULTS OBSERVED BY THE CUSTOMER WERE TESTED IN MAY 2024 AND JUNE 2024, AND ONLY ONE VALID RESULT WAS OBTAINED (0.33 G/L FOR THE 4:1 DILUTION, OTHER RESULTS GENERATED A FLAG AND DID NOT DISPLAY NUMERICAL RESULTS). THE HISTORICAL RESULTS ON THE ALTERNATE METHOD WHICH THE CUSTOMER CONSIDERED CORRECT WERE TESTED FROM FEBRUARY 2023 TO NOVEMBER 2023, AND RESULTS RANGED FROM 0.5 TO 0.8 G/L ON THE ALTERNATE METHOD DURING THIS TIMEFRAME. NO DIRECT COMPARISON OF A PATIENT RESULT IS GIVEN AS THERE ARE SEVERAL MONTHS BETWEEN THE SYSMEX CS-5100 SYSTEM RESULTS AND THE ALTERNATE METHOD RESULTS. THERE ARE MANY REASONS WHICH MIGHT INTERFERE ON THE PATIENT. A CERTAIN DEVIATION BETWEEN TO DIFFERENT TESTING SYSTEMS MUST BE EXPECTED DEPENDING ON THE TECHNIQUE, METHOD, EQUIPMENT AND REAGENT LOT USED. REAGENT ISSUES WERE RULED OUT BASED ON REVIEW OF QUALITY CONTROL (QC), WHICH SHOWED RECOVERY WITHIN ACCEPTABLE RANGES, AND NO ISSUES WERE REPORTED WITH OTHER PATIENT SAMPLES. BASED ON THE AVAILABLE INFORMATION, THE CAUSE OF THE DISCORDANT RESULT IS INCONCLUSIVE. THE CUSTOMER IS OPERATIONAL, AND THE REPORTED ISSUE IS RESOLVED BY ROUTINE TROUBLESHOOTING. SIEMENS HAS NO INDICATION ON A POTENTIAL PERFORMANCE ISSUE WITH NEITHER INSTRUMENT NOR REAGENT. THE DADE THROMBIN REAGENT IS PERFORMING AS INTENDED. A PRODUCT PERFORMANCE ISSUE HAS NOT BEEN IDENTIFIED.

    Description of Event or Problem · 0

    THE CUSTOMER REPORTED THE OBSERVATION OF FALSELY DEPRESSED FIBRINOGEN RESULTS ON ONE PATIENT MEASURED WITH THE SIEMENS DADE THROMBIN REAGENT ON A SYSMEX CS-5100 SYSTEM (LEGAL MANUFACTURER: SYSMEX) COMPARED TO THE HISTORICAL FIBRINOGEN RESULTS OBTAINED ON AN ALTERNATE METHOD. THE PATIENT SAMPLE WAS PROCESSED IN 1:1 AND 4:1 DILUTIONS. FOR BOTH DILUTION RESULTS, THE INSTRUMENT GENERATED A FLAG AND DID NOT DISPLAY NUMERICAL RESULTS. HOWEVER, THE USER IGNORED OR MISINTERPRETED THE MESSAGE OR FLAG AND REPORTED THE RESULTS (AS <0.3 G/L) TO THE PHYSICIAN(S), WHO QUESTIONED THE RESULTS. THERE ARE NO KNOWN REPORTS OF PATIENT INTERVENTION OR ADVERSE HEALTH CONSEQUENCES DUE TO THE FALSELY DEPRESSED FIBRINOGEN RESULTS.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    356534 DADE® THROMBIN REAGENT SYSTEM, FIBRINOGEN DETERMINATION KQJ SIEMENS HEALTHCARE DIAGNOSTICS PRODUCTS GMBH N/A 567436 00842768003950

    Patients

    Seq Age Sex Outcome Treatment
    1 NA Unknown