COULTER® LH 780 HEMATOLOGY ANALYZER
Report
- Report Number
- 1061932-2012-02753
- Event Type
- Malfunction
- Date Received
- November 21, 2012
- Date of Event
- October 24, 2012
- Report Date
- October 24, 2012
- Manufacturer
- BECKMAN COULTER INC.
- Product Code
- GKZ
- PMA / PMN Number
- K061574
- Removal / Correction Number
- N/A
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- IN, US
- Reporter Occupation
- HEALTH PROFESSIONAL
Narratives
THE RAW DATA ANALYSIS INDICATED THAT THE HISTOGRAMS SHOW A SLIGHTLY TILTED NEUTROPHIL POPULATION, A SLIGHTLY HIGH MONOCYTE PERCENT, AND SCATTERED NOISY EVENTS IN THE HIGH DIRECT CURRENT (DC) AREA. HOWEVER, THESE CHARACTERISTICS WERE NOT SIGNIFICANT ENOUGH FOR THE ALGORITHM TO SET A BLAST FLAG FOR THE SAMPLES INVOLVED IN THIS EVENT. FAILURE MODE (FINAL INVESTIGATION): THE CHARACTERISTICS OF THE PATIENT SAMPLES WERE NOT SIGNIFICANT ENOUGH FOR THE ALGORITHM TO SET A BLAST FLAG.
CONTROLS WERE RUN BEFORE THE INCIDENT AND WERE WITHIN SPECIFICATIONS. NO CONTROLS WERE RUN AFTER THE INCIDENT. PER THE INFORMATION PROVIDED, THE BLAST FLAGGING PREFERENCE WAS SET AT MID-LEVEL FOR BOTH INSTRUMENTS. A BEC FIELD SERVICE ENGINEER (FSE) WAS DISPATCHED ON (B)(4) 2012 FOR THIS EVENT. THE FSE VERIFIED THE FLOW CELL BY THE USUAL TEST AND INSPECTION PROCESS WITH CONTROLS AND LATRON. THE FSE ALSO VERIFIED THAT THE INSTRUMENT WAS ANALYZING ABOVE 7900 CELLS ON WHOLE BLOOD SPECIMENS. PUMP VOLUMES ON LYSE AND STABILYSE WERE ALSO CHECKED. FAILURE MODE IS CURRENTLY UNKNOWN. THE FOLLOWING MDRS ARE ASSOCIATED WITH THIS EVENT DOCUMENTED IN THIS REPORT: 1061932-2012-02752 AND 1061932-2012-02754.
THIS IS A FOLLOW UP REPORT.
A CUSTOMER CONTACTED BECKMAN COULTER INC. (BEC) REPORTING THAT BLAST SUSPECT FLAGS WERE NOT OBTAINED ON TWO (2) DIFFERENT ANALYZERS - COULTER LH 780 HEMATOLOGY ANALYZER (SERIAL # (B)(4)) AND COULTER LH 750 HEMATOLOGY ANALYZER (SERIAL # (B)(4)) , ON TWO (2) SEPARATE DAYS ((B)(6) 2012), FOR ONE PATIENT WITH BLASTS CELLS IDENTIFIED BY MANUAL SMEARS. THIS REPORT DOCUMENTS THE RESULTS GENERATED BY THE LH 780 INSTRUMENT (SERIAL # (B)(4)) ON (B)(6) 2012. THE CUSTOMER INDICATED THAT NO BLAST FLAGGING MESSAGES WERE GENERATED. IN ADDITION, AN ERRONEOUS MONOCYTE (MO%) RESULT WAS ALSO OBTAINED COMPARED TO THE MANUAL RESULTS. THE RESULTS WERE REPORTED OUT OF THE LABORATORY; HOWEVER, THERE WAS NO IMPACT TO PATIENT TREATMENT.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 1 | COULTER® LH 780 HEMATOLOGY ANALYZER | COUNTER, DIFFERENTIAL CELL | GKZ | BECKMAN COULTER INC. | LH 780 | N/A |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 |