FDA Adverse Event Malfunction Summary report: N

VITROS CHEMISTRY PRODUCTS PHBR SLIDES

MDR report key: 2880313 · Received December 19, 2012

Report

Report Number
1319809-2012-00267
Event Type
Malfunction
Date Received
December 19, 2012
Date of Event
November 21, 2012
Report Date
December 19, 2012
Manufacturer
ORTHO-CLINICAL DIAGNOSTICS
Product Code
DLZ
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
FL, US
Reporter Occupation
OTHER

Narratives

Additional Manufacturer Narrative · 1

THE INVESTIGATION DETERMINED THAT IMPRECISE VITROS PHBR QUALITY CONTROL RESULTS WERE OBTAINED ON A VITROS 5,1 FS CHEMISTRY SYSTEM. THERE IS NO EVIDENCE THAT AN INSTRUMENT RELATED ISSUE CONTRIBUTED TO THE EVENT. THE MOST LIKELY CAUSE OF THE EVENT IS REAGENT RELATED ISSUE. ADDITIONALLY, AN ATYPICAL CALIBRATION OF AN UNKNOWN CAUSE WAS IN USE AT THE TIME OF THE EVENT. EXPECTED PERFORMANCE WAS RETURNED USING AN ALTERNATE REAGENT LOT. INTERNAL INVESTIGATION IS ONGOING.

Description of Event or Problem · 1

A CUSTOMER OBTAINED IMPRECISE VITROS PHBR QUALITY CONTROL RESULTS RUN ON A VITROS 5,1 FS CHEMISTRY SYSTEM. QC LOT M1914= 78.0, 77.4, >80.0, 75.9, >80.0, 77.5, 78.4, 78.6, >80.0, 75.6, 75.3, 40.2, 47.4, 43.0, 46.9, 47.6, 46.4, 41.2, 79.9, 48.6, 31.9, 45.8 VS. AN EXPECTED RESULT= 62.7 UG/ML. BIASED RESULTS OF THE MAGNITUDE AND DIRECTION OBSERVED MAY LEAD TO INAPPROPRIATE PHYSICIAN ACTION IF THEY WERE TO OCCUR UNDETECTED ON PATIENT SAMPLES. HOWEVER, NO VITROS PHBR PATIENT RESULTS WERE REPORTED DURING THE TIME FRAME OF THE EVENT. THERE WAS NO REPORT OF PATIENT HARM AS A RESULT OF THIS EVENT. THIS REPORT IS NUMBER FIVE OF TWENTY TWO MDR'S FOR THIS EVENT. TWENTY TWO 3500A FORMS ARE BEING SUBMITTED FOR THIS EVENT AS TWENTY TWO DEVICES WERE INVOLVED. (B)(4).

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 VITROS CHEMISTRY PRODUCTS PHBR SLIDES IN-VITRO DIAGNOSTIC DLZ ORTHO-CLINICAL DIAGNOSTICS 2538-0060-7596

Patients

Seq Age Sex Outcome Treatment
1