FDA Adverse Event Malfunction Summary report: N

DIMENSION® CLINICAL CHEMISTRY SYSTEM

MDR report key: 2490053 · Received March 13, 2012

Report

Report Number
2517506-2012-00052
Event Type
Malfunction
Date Received
March 13, 2012
Date of Event
March 1, 2012
Report Date
March 2, 2012
Manufacturer
SIEMENS HEALTHCARE DIAGNOSTICS INC - GLASGOW
Product Code
JFY
PMA / PMN Number
K073055
Removal / Correction Number
2517506-02-22-2013-002-C
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
AZ, US
Reporter Occupation
MEDICAL TECHNOLOGIST

Narratives

Additional Manufacturer Narrative · 1

ANALYSIS OF THE INSTRUMENT AND INSTRUMENT DATA INDICATE THAT THE CAUSE FOR THE FALSELY DEPRESSED CREATININE RESULTS IS UNKNOWN. THE INSTRUMENT IS PERFORMING WITHIN SPECIFICATIONS. NO FURTHER EVALUATION OF THE DEVICE IS REQUIRED.

Additional Manufacturer Narrative · 1

SIEMENS FILED THE ORIGINAL MDR (B)(4) /2012. ADDITIONAL INFORMATION: SIEMENS HEALTHCARE DIAGNOSTICS INC. HAS CONFIRMED CUSTOMER COMPLAINTS OF FALSELY DEPRESSED ENZYMATIC CREATININE (EZCR) RESULTS WHEN EZCR IS PROCESSED FROM OPEN WELLS OF ENZYMATIC CREATININE (EZCR) FLEX REAGENT CARTRIDGES THAT ARE IN CLOSE PROXIMITY TO OPEN WELLS OF PHOSPHORUS (PHOS) FLEX REAGENT CARTRIDGES. THE FALSELY DEPRESSED EZCR RESULTS ARE CAUSED BY A EZCR REAGENT INTERACTION WITH THE PHOS REAGENT. AN URGENT MEDICAL DEVICE CORRECTION FOR THE PHOS FLEX REAGENT CARTRIDGE (DF61), COMMUNICATION #(B)(4) WAS ISSUED IN (B)(4) 2013 TO IMPACTED CUSTOMERS. THE COMMUNICATION PROVIDED REMEDIAL ACTIONS TO CUSTOMERS TO EITHER AVOID THE REAGENT INTERACTIONS OR TO DISCONTINUE THE USE OF EITHER PHOS OR EZCR ON THEIR DIMENSION SYSTEM.

Description of Event or Problem · 1

A GROUP OF FALSELY DEPRESSED CREATININE RESULT WERE OBTAINED ON PATIENT SAMPLES. SOME PATIENT RESULTS WAS REPORTED TO THE PHYSICIAN. QC WAS RUN AND LOW RECOVERIES PROMPTED RERUN OF PRIOR SAMPLES. THE TESTS WERE REPEATED AND HIGHER RESULTS WERE OBTAINED. IT IS UNKNOWN IF PATIENT TREATMENT WAS ALTERED OR PRESCRIBED AS A RESULT OF THE FALSELY DEPRESSED CREATININE RESULTS. THERE WAS NO REPORT OF ADVERSE HEALTH CONSEQUENCES AS A RESULT OF THE FALSELY DEPRESSED CREATININE RESULTS.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 DIMENSION® CLINICAL CHEMISTRY SYSTEM ENZYMATIC CREATININE FLEX® REAGENT CARTRIDGE JFY SIEMENS HEALTHCARE DIAGNOSTICS INC - GLASGOW GA2323

Patients

Seq Age Sex Outcome Treatment
1