FDA Adverse Event Malfunction Summary report: N

UNICEL DXC 600 SYNCHRON CLINICAL SYSTEM

MDR report key: 2256450 · Received August 19, 2011

Report

Report Number
2050012-2011-04646
Event Type
Malfunction
Date Received
August 19, 2011
Date of Event
November 20, 2008
Report Date
November 20, 2008
Manufacturer
BECKMAN COULTER, INC.
Product Code
JJE
PMA / PMN Number
K042291
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
CA, US
Reporter Occupation
OTHER HEALTH CARE PROFESSIONAL

Narratives

Additional Manufacturer Narrative · 1

THE SYSTEM WAS EVALUATED BY A BCI FIELD SERVICE ENGINEER (FSE). THE FSE FOUND THAT THE CL CALIBRATION HAD FAILED. THE FSE REPLACED THE CL ELECTRODE. THIS REPORTABLE EVENT WAS IDENTIFIED DURING A RETROSPECTIVE REVIEW OF COMPLAINTS CONDUCTED BETWEEN JANUARY 01, 2008 AND OCTOBER 23, 2010 FOR ADDITIONAL REPORTABLE EVENTS.

Description of Event or Problem · 1

THE CUSTOMER CONTACTED BECKMAN COULTER, INC. (BCI) TO REPORT THAT THEIR UNICEL DXC 600 SYNCHRON CLINICAL SYSTEM GAVE ERRONEOUSLY LOW CHLORIDE (CL) RESULTS. THE ERRONEOUS RESULTS WERE NOT REPORTED OUTSIDE OF THE LABORATORY. PATIENT TREATMENT WAS NOT AFFECTED BY THIS EVENT AND THERE WERE NO REPORTS OF DEATH OR SERIOUS INJURY. THE ERRONEOUS RESULTS WERE RERUN ON A SYNCHRON LX20 SYSTEM AND WERE CONSIDERED NORMAL. PRIOR TO THE EVENT, THE ION SELECTIVE ELECTRODE (ISE) SYSTEM WAS CALIBRATED AND A QUALITY CONTROL (QC) WAS RUN. THE QC RECOVERED WITHIN THE LAB'S ESTABLISHED RANGES.

Additional Manufacturer Narrative · 2

THE SYSTEM WAS EVALUATED BY A BCI FIELD SERVICE ENGINEER (FSE). THE FSE FOUND THAT THE CL CALIBRATION HAD FAILED. THE FSE REPLACED THE CL ELECTRODE. THIS REPORTABLE EVENT WAS IDENTIFIED DURING A RETROSPECTIVE REVIEW OF COMPLAINTS CONDUCTED BETWEEN JANUARY 01, 2008 AND OCTOBER 23, 2010 FOR ADDITIONAL REPORTABLE EVENTS.

Description of Event or Problem · 2

THE CUSTOMER CONTACTED BECKMAN COULTER, INC. (BCI) TO REPORT THAT THEIR UNICEL DXC 600 SYNCHRON CLINICAL SYSTEM GAVE ERRONEOUSLY LOW CHLORIDE (CL) RESULTS. THE ERRONEOUS RESULTS WERE NOT REPORTED OUTSIDE OF THE LABORATORY. PATIENT TREATMENT WAS NOT AFFECTED BY THIS EVENT AND THERE WERE NO REPORTS OF DEATH OR SERIOUS INJURY. THE ERRONEOUS RESULTS WERE RERUN ON A SYNCHRON LX20 SYSTEM AND WERE CONSIDERED NORMAL. PRIOR TO THE EVENT, THE ION SELECTIVE ELECTRODE (ISE) SYSTEM WAS CALIBRATED AND A QUALITY CONTROL (QC) WAS RUN. THE QC RECOVERED WITHIN THE LAB'S ESTABLISHED RANGES.

Additional Manufacturer Narrative · 3

THE SYSTEM WAS EVALUATED BY A BCI FIELD SERVICE ENGINEER (FSE). THE FSE FOUND THAT THE CL CALIBRATION HAD FAILED. THE FSE REPLACED THE CL ELECTRODE. THIS REPORTABLE EVENT WAS IDENTIFIED DURING A RETROSPECTIVE REVIEW OF COMPLAINTS CONDUCTED BETWEEN JANUARY 01, 2008 AND OCTOBER 23, 2010 FOR ADDITIONAL REPORTABLE EVENTS.

Description of Event or Problem · 3

THE CUSTOMER CONTACTED BECKMAN COULTER, INC. (BCI) TO REPORT THAT THEIR UNICEL DXC 600 SYNCHRON CLINICAL SYSTEM GAVE ERRONEOUSLY LOW CHLORIDE (CL) RESULTS. THE ERRONEOUS RESULTS WERE NOT REPORTED OUTSIDE OF THE LABORATORY. PATIENT TREATMENT WAS NOT AFFECTED BY THIS EVENT AND THERE WERE NO REPORTS OF DEATH OR SERIOUS INJURY. THE ERRONEOUS RESULTS WERE RERUN ON A SYNCHRON LX20 SYSTEM AND WERE CONSIDERED NORMAL. PRIOR TO THE EVENT, THE ION SELECTIVE ELECTRODE (ISE) SYSTEM WAS CALIBRATED AND A QUALITY CONTROL (QC) WAS RUN. THE QC RECOVERED WITHIN THE LAB'S ESTABLISHED RANGES.

Additional Manufacturer Narrative · 4

H3, H6: THE SYSTEM WAS EVALUATED BY A BCI FIELD SERVICE ENGINEER (FSE). THE FSE FOUND THAT THE CL CALIBRATION HAD FAILED. THE FSE REPLACED THE CL ELECTRODE. THIS REPORTABLE EVENT WAS IDENTIFIED DURING A RETROSPECTIVE REVIEW OF COMPLAINTS CONDUCTED BETWEEN JANUARY 01, 2008 AND OCTOBER 23, 2010 FOR ADDITIONAL REPORTABLE EVENTS.

Description of Event or Problem · 4

THE CUSTOMER CONTACTED BECKMAN COULTER, INC. (BCI) TO REPORT THAT THEIR UNICEL DXC 600 SYNCHRON CLINICAL SYSTEM GAVE ERRONEOUSLY LOW CHLORIDE (CL) RESULTS. THE ERRONEOUS RESULTS WERE NOT REPORTED OUTSIDE OF THE LABORATORY. PATIENT TREATMENT WAS NOT AFFECTED BY THIS EVENT AND THERE WERE NO REPORTS OF DEATH OR SERIOUS INJURY. THE ERRONEOUS RESULTS WERE RERUN ON A SYNCHRON LX20 SYSTEM AND WERE CONSIDERED NORMAL. PRIOR TO THE EVENT, THE ION SELECTIVE ELECTRODE (ISE) SYSTEM WAS CALIBRATED AND A QUALITY CONTROL (QC) WAS RUN. THE QC RECOVERED WITHIN THE LAB'S ESTABLISHED RANGES.

Additional Manufacturer Narrative · 5

H3, H6: THE SYSTEM WAS EVALUATED BY A BCI FIELD SERVICE ENGINEER (FSE). THE FSE FOUND THAT THE CL CALIBRATION HAD FAILED. THE FSE REPLACED THE CL ELECTRODE. THIS REPORTABLE EVENT WAS IDENTIFIED DURING A RETROSPECTIVE REVIEW OF COMPLAINTS CONDUCTED BETWEEN JANUARY 01, 2008 AND OCTOBER 23, 2010 FOR ADDITIONAL REPORTABLE EVENTS.

Description of Event or Problem · 5

THE CUSTOMER CONTACTED BECKMAN COULTER, INC. (BCI) TO REPORT THAT THEIR UNICEL DXC 600 SYNCHRON CLINICAL SYSTEM GAVE ERRONEOUSLY LOW CHLORIDE (CL) RESULTS. THE ERRONEOUS RESULTS WERE NOT REPORTED OUTSIDE OF THE LABORATORY. PATIENT TREATMENT WAS NOT AFFECTED BY THIS EVENT AND THERE WERE NO REPORTS OF DEATH OR SERIOUS INJURY. THE ERRONEOUS RESULTS WERE RERUN ON A SYNCHRON LX20 SYSTEM AND WERE CONSIDERED NORMAL. PRIOR TO THE EVENT, THE ION SELECTIVE ELECTRODE (ISE) SYSTEM WAS CALIBRATED AND A QUALITY CONTROL (QC) WAS RUN. THE QC RECOVERED WITHIN THE LAB'S ESTABLISHED RANGES.

Additional Manufacturer Narrative · 6

H3, H6: THE SYSTEM WAS EVALUATED BY A BCI FIELD SERVICE ENGINEER (FSE). THE FSE FOUND THAT THE CL CALIBRATION HAD FAILED. THE FSE REPLACED THE CL ELECTRODE. THIS REPORTABLE EVENT WAS IDENTIFIED DURING A RETROSPECTIVE REVIEW OF COMPLAINTS CONDUCTED BETWEEN JANUARY 01, 2008 AND OCTOBER 23, 2010 FOR ADDITIONAL REPORTABLE EVENTS.

Description of Event or Problem · 6

THE CUSTOMER CONTACTED BECKMAN COULTER, INC. (BCI) TO REPORT THAT THEIR UNICEL DXC 600 SYNCHRON CLINICAL SYSTEM GAVE ERRONEOUSLY LOW CHLORIDE (CL) RESULTS. THE ERRONEOUS RESULTS WERE NOT REPORTED OUTSIDE OF THE LABORATORY. PATIENT TREATMENT WAS NOT AFFECTED BY THIS EVENT AND THERE WERE NO REPORTS OF DEATH OR SERIOUS INJURY. THE ERRONEOUS RESULTS WERE RERUN ON A SYNCHRON LX20 SYSTEM AND WERE CONSIDERED NORMAL. PRIOR TO THE EVENT, THE ION SELECTIVE ELECTRODE (ISE) SYSTEM WAS CALIBRATED AND A QUALITY CONTROL (QC) WAS RUN. THE QC RECOVERED WITHIN THE LAB'S ESTABLISHED RANGES.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 UNICEL DXC 600 SYNCHRON CLINICAL SYSTEM JJE BECKMAN COULTER, INC. NA NA

Patients

Seq Age Sex Outcome Treatment
1 58 YR
2 56 YR
3 68 YR
4 75 YR
5 72 YR
6 68 YR