RAPIDPOINT 500E BLOOD GAS SYSTEM
Report
- Report Number
- 3002637618-2025-00064
- Event Type
- Malfunction
- Date Received
- August 18, 2025
- Date of Event
- August 4, 2025
- Report Date
- September 16, 2025
- Manufacturer
- SIEMENS HEALTHCARE DIAGNOSTICS INC.
- Product Code
- CHL
- UDI-DI
- 00630414286174
- PMA / PMN Number
- K192240
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- GM
- Reporter Occupation
- OTHER HEALTH CARE PROFESSIONAL
- Health Professional
- Yes
Narratives
ASSESSMENT OF THE INSTRUMENT DATA PROVIDED BY THE CUSTOMER SHOWED ¿SODIUM SENSOR INTERFERENT DETECTED¿ MESSAGES ON THE DATE OF THE EVENT, BEFORE THE REPORTED SAMPLE MEASUREMENTS. THIS IS AN INDICATION OF NA+ SENSOR EXPOSURE TO QUATERNARY AMMONIUM COMPOUNDS (QACS) SUCH AS BENZALKONIUM FOUND IN MANY SKIN DISINFECTANTS OR EXTERIOR CLEANERS. PER THE CUSTOMER BULLETINS AND THE RAPIDPOINT 500 OPERATOR¿S GUIDE IT IS RECOMMENDED NOT TO USE ANY SKIN DISINFECTING PRODUCTS AND/OR EXTERIOR DISINFECTANTS THAT CONTAIN QUATERNARY AMMONIUM COMPOUNDS (QAC) AS THEY ARE KNOWN INTERFERENTS TO THE RP500/500E NA+ SENSOR BY POTENTIALLY IMPACTING THE SENSOR AND ITS¿ PERFORMANCE AND SHOULD BE AVOIDED. THE SOURCE CONTAINING QAC WAS NOT DISCLOSED TO SIEMENS HOWEVER IT HAS BEEN RECOMMENDED THAT THEY IDENTIFY AND CEASE USE OF THE SOURCE. THE ROOT CAUSE FOR THE DISCREPANT LOW NA+ RESULT WAS DUE TO USER ERROR FROM THE MOMENTARY INSTABILITY OF THE NA+ SENSOR FROM AN INTERFERENT WHEN THE SAMPLES IN QUESTION WERE RUN. THE MEASUREMENT CARTRIDGE WAS CHANGED AND THE INSTRUMENT IS PERFORMING AS INTENDED AND IS CURRENTLY OPERATIONAL.
THE CUSTOMER REPLACED THE MEASUREMENT CARTRIDGE AND THE SYSTEM IS OPERATIONAL. THE CUSTOMER PROVIDED INSTRUMENT FILES FOR FURTHER INVESTIGATION. INVESTIGATION IS UNDERWAY. THE CAUSE OF THIS EVENT IS UNKNOWN.
THE CUSTOMER REPORTED A DISCREPANT LOW NA+ RESULT ON A PATIENT SAMPLE WHEN COMPARED TO A REPEAT ON A LABORATORY ANALYZER. THERE IS NO REPORT OF INJURY DUE TO THIS EVENT.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 1679289 | RAPIDPOINT 500E BLOOD GAS SYSTEM | RAPIDPOINT 500E BLOOD GAS SYSTEM | CHL | SIEMENS HEALTHCARE DIAGNOSTICS INC. | 00630414286174 |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | NA | Unknown |