FDA Adverse Event Injury Summary report: N

COAGUCHEK ® XS SYSTEM

MDR report key: 2141071 · Received June 27, 2011

Report

Report Number
1823260-2011-03465
Event Type
Injury
Date Received
June 27, 2011
Date of Event
May 27, 2011
Report Date
June 28, 2011
Manufacturer
ROCHE DIAGNOSTICS
Product Code
GJS
PMA / PMN Number
K062925
Removal / Correction Number
NA
Adverse Event
Yes
Report Source
Manufacturer report
Reporter Location
CO, US
Reporter Occupation
NURSE

Narratives

Additional Manufacturer Narrative · 1

IT WAS UNKNOWN IF THE INITIAL REPORTER SENT REPORT TO THE FDA.

Description of Event or Problem · 1

CALLER STATES PATIENT TESTED 2.0 INR ON THE COAGUCHEK XS SYSTEM. PATIENT WAS TAKEN TO THE HOSPITAL COMPLAINING OF PAIN; A LAB VALUE RETURNED AS 11.6 INR APPROXIMATELY 6.5 HOURS AFTER PATIENT'S METER RESULT OF 2.0 INR. PATIENT WAS TREATED WITH VITAMIN K AND ADMITTED TO THE HOSPITAL FOR 3 DAYS. CALLER NOTED PATIENT WAS MISSING 8-9 COUMADIN TABLETS; CALLER BELIEVES PATIENT INADVERTENTLY TOOK COUMADIN INSTEAD OF HER PAIN MEDICATION. PATIENT AND PATIENT'S FAMILY HAVE DENIED THIS. PATIENT'S CONDITION HAS IMPROVED. REQUESTED RETURN OF SUSPECT DEVICE AND REPLACEMENT WAS SENT.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 COAGUCHEK ® XS SYSTEM PROTHROMBIN TIME TEST STRIPS GJS ROCHE DIAGNOSTICS NA 20183231

Patients

Seq Age Sex Outcome Treatment
1 080 YR Hospitalization| R OXYCONTIN "IR"| PRILOSEC| TYLENOL| NASONEX DAILY| "ALLERGY" EYE DROPS| CPM MACHINE| MEDROXYPROGESTERONE| "ESTROGEN"| MOISTURIZING EYE DROPS| COUMADIN| WALKER| LISINOPRIL DAILY| CLARINEX DAILY