BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    PHOS2

    MDR report key: 20348054 · Received October 1, 2024

    Report

    Report Number
    1823260-2024-02841
    Event Type
    Malfunction
    Date Received
    October 1, 2024
    Date of Event
    September 9, 2024
    Report Date
    December 3, 2024
    Manufacturer
    ROCHE DIAGNOSTICS
    Product Code
    CEO
    UDI-DI
    04015630918973
    PMA / PMN Number
    K951595
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CI
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL
    Health Professional
    Yes

    Narratives

    Additional Manufacturer Narrative · 0

    THE CUSTOMER WAS USING PHOSPHORUS REAGENT LOT 78223201 (EXPIRATION DATE = 31-MAY-2025) ON 09-SEP-2024. THE CUSTOMER STARTED USING PHOSPHORUS REAGENT LOT NUMBER 801953 ON 01-OCT-2024. THE EXPIRATION DATE FOR THIS LOT NUMBER WAS NOT PROVIDED. THE SAME PATIENT HAD 3 ADDITIONAL SAMPLES TESTED ON BOTH ANALYZERS, RESULTING IN THE FOLLOWING VALUES: A SAMPLE COLLECTED FROM THE PATIENT (SAMPLE 2) ON (B)(6) 2024 RESULTED IN A PHOSPHORUS VALUE OF < 0.176 MG/DL WITH A DATA FLAG ON (B)(6) 2024. THE SAMPLE WAS REPEATED ON A DIFFERENT C 501 ANALYZER, RESULTING IN A PHOSPHORUS VALUE OF 0.30 MG/DL ON (B)(6) 2024. A SECOND SAMPLE COLLECTED FROM THE PATIENT (SAMPLE 3) ON (B)(6) 2024 RESULTED IN A PHOSPHORUS VALUE OF 0.437 MG/DL ON (B)(6) 2024. A THIRD SAMPLE COLLECTED FROM THE PATIENT (SAMPLE 4) ON (B)(6) 2024 RESULTED IN A PHOSPHORUS VALUE OF 0.581 MG/DL ON (B)(6) 2024. MEDICATIONS WERE ADMINISTERED TO THE PATIENT PRIOR TO EACH SAMPLE COLLECTION. THE PATIENT HAS HAD NO HEALTH PROBLEMS DUE TO PHOSPHORUS LOADING. MEDWATCH FIELD D4 HAS BEEN UPDATED.

    Additional Manufacturer Narrative · 0

    CALIBRATION AND CONTROLS WERE ACCEPTABLE. UPON REVIEW OF THE ALARM TRACE, 2 ABNORMAL ASPIRATION ALARMS OCCURRED NEAR THE TIME OF THE EVENT. BASED ON ANALYSIS OF THE REACTION DATA, AN ASSAY INTERFERENCE IS UNLIKELY. THE INVESTIGATION DETERMINED THAT THE ISSUE IS CONSISTENT WITH PHYSIOLOGICAL ALTERATIONS TO THE PATIENT'S PHOSPHORUS LEVELS BASED ON MEDICATIONS THE PATIENT WAS TAKING. THE PATIENT WAS TAKING FUROSEMIDE, WHICH CAN CAUSE HYPOPHOSPHATEMIA DUE TO INCREASED EXCRETION OF PHOSPHORUS IN THE URINE. THE PATIENT WAS ALSO TAKING PREDNISONE WHICH MAY CAUSE HYPOPHOSPHATEMIA BY AFFECTING PHOSPHORUS METABOLISM.

    Additional Manufacturer Narrative · 0

    THE SERIAL NUMBER OF THE C501 ANALYZER IS (B)(6). THE SERIAL NUMBER OF THE C 503 ANALYZER WAS REQUESTED, BUT NOT PROVIDED. THE INVESTIGATION IS ONGOING. MEDWATCH FIELD E1 PHONE NUMBER WAS PROVIDED AS (B)(6).

    Description of Event or Problem · 0

    THE INITIAL REPORTER STATED THEY RECEIVED QUESTIONABLE RESULTS FOR SAMPLES FROM THE SAME PATIENT TESTED WITH PHOS2 (PHOSPHORUS) ON A COBAS 6000 C501 MODULE AND A COBAS C 503 ANALYTICAL UNIT. AT LEAST 4 SAMPLES FROM THE PATIENT HAVE RESULTED IN PHOSPHORUS VALUES OF < 0.181 MG/DL ACCOMPANIED BY A DATA FLAG WHEN TESTED ON EITHER THE C 501 OR C 503 SYSTEMS. THE RESULTS DID NOT MATCH THE PATIENT'S CLINICAL DIAGNOSIS. DATA WAS PROVIDED FOR ONE SPECIFIC SAMPLE TESTED ON (B)(6) 2024. THIS SAMPLE INITIALLY RESULTED IN A PHOSPHORUS VALUE OF < 0.181 MG/DL ACCOMPANIED BY A DATA FLAG WHEN TESTED ON THE C 501 MODULE. THIS SAMPLE WAS SENT TO ANOTHER SITE WHERE IT WAS TESTED ON A VITROS ANALYZER, RESULTING IN A PHOSPHORUS VALUE OF 1.1 MG/DL.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    34222 PHOS2 PHOSPHOMOLYBDATE (COLORIMETRIC), INORGANIC PHOSPHORUS CEO ROCHE DIAGNOSTICS 782232, 801953 04015630918973

    Patients

    Seq Age Sex Outcome Treatment
    1 75 YR Male AMLODIPINE| DALTEPARIN| DROPERIDOL| ESOMEPRAZOLE| FUROSEMIDE| HALOPERIDOL| INSULINE LANTUS SOLOSTAR| LEVOCETIRIZINE| LOPERAMIDE| LOSARTAN| OLANZAPINE| PARACETAMOL| PREDNISONE| SALMETEROL/FLUTIC| TAMSULOSIN| TRAZODONE| VALPROIC ACID