BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    COAGUCHEK ® XS SYSTEM

    MDR report key: 2163052 · Received July 15, 2011

    Report

    Report Number
    1823260-2011-03762
    Event Type
    Malfunction
    Date Received
    July 15, 2011
    Date of Event
    June 27, 2011
    Report Date
    August 19, 2011
    Manufacturer
    ROCHE DIAGNOSTICS
    Product Code
    GJS
    PMA / PMN Number
    K062925
    Removal / Correction Number
    NA
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    PA, 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 2.2 INR ON THE COAGUCHEK XS SYSTEM WHILE A COMPARISON LAB RETURNED AS 1.7 INR. NO ACTIONS TAKEN BASED ON DEVICE RESULT. NO ADVERSE EVENT REPORTED. REQUESTED RETURN OF SUSPECT SYSTEM 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 20318211

    Patients

    Seq Age Sex Outcome Treatment
    1 089 YR BABY ASPIRIN ONCE DAILY| LIPITOR ONCE DAILY| MIRALAX| SYNTHROID ONCE DAILY| GLUCOTROL XL ONCE DAILY| VITAMIN B12 2/DAY| LASIX DAILY| TYLENOL ARTHRITIS PAIN| METOPROLOL TARTRATE 2/DAY| VITAMIN B6 2/DAY| METAMUCIL| NEXIUM ONCE DAILY| COUMADIN| CARDIZEM CD ONCE DAILY| COLACE AT BEDTIME| NITROGLYCERIN