FDA Adverse Event Malfunction Summary report: N

UNICEL® DXH 800 COULTER® CELLULAR ANALYSIS SYSTEM

MDR report key: 2880678 · Received December 20, 2012

Report

Report Number
1061932-2012-02848
Event Type
Malfunction
Date Received
December 20, 2012
Date of Event
November 20, 2012
Report Date
November 21, 2012
Manufacturer
BECKMAN COULTER INC.
Product Code
GKZ
PMA / PMN Number
K081930
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
VA, US
Reporter Occupation
HEALTH PROFESSIONAL

Narratives

Additional Manufacturer Narrative · 1

A BECKMAN COULTER FIELD SERVICE ENGINEER (FSE) VISITED THE SITE AND EXAMINED THE SYSTEM. THE FSE FOUND THAT THE SYSTEM HAD POOR FLOW CELL PHASE ALIGNMENT. THE FSE REPLACED THE FLOWCELL, MAL SENSOR, AND SAMPLE LINE. THE FSE THEN PERFORMED A FLOW CELL PHASE ALIGNMENT WHICH RESOLVED THE ISSUE. SERVICE WAS VERIFIED FOLLOWING ESTABLISHED PROCEDURES AND THE INSTRUMENT CONFORMS TO PUBLISHED SPECIFICATIONS. THIS IS ONE OF TWO INDIVIDUAL MEDWATCH REPORTS BEING SUBMITTED AS TWO SEPARATE DEVICES WERE INVOLVED. REFERENCE MEDWATCH NUMBERS 1061932-2012-02847 AND 106-1932-2012-02848 FOR ALL ASSOCIATED REPORTS. THE SAME PATIENT SAMPLE IS INVOLVED IN EACH REPORT.

Description of Event or Problem · 1

A CUSTOMER CONTACTED BECKMAN COULTER INC. (BEC) REPORTING THAT ERRONEOUS HIGH NE (NEUTROPHIL) AND LOW MO (MONOCYTE) RESULTS WERE GENERATED BY THE UNICEL DXH 800 COULTER CELLULAR ANALYSIS SYSTEM WITHOUT INSTRUMENT GENERATED FLAGS. THIS SAME PATIENT SAMPLE WAS PREVIOUSLY TESTED ON ANOTHER SYSTEM AND YIELDED THE SAME INITIAL ERRONEOUS RESULT. THE SAMPLE WAS RETESTED AND YIELDED CORRECT RESULTS CONSISTENT WITH A RESULT FROM A PREVIOUS DAY'S INSTRUMENT RESULTS AND MANUAL SMEAR RESULTS FOR A SINGLE PATIENT. THERE WERE NO INJURIES OR CHANGES TO THE PATIENTS CARE OR TREATMENT. A BECKMAN COULTER FIELD SERVICE ENGINEER WAS DISPATCHED TO THE SITE TO EVALUATE THE SYSTEM.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1 UNICEL® DXH 800 COULTER® CELLULAR ANALYSIS SYSTEM COUNTER, DIFFERENTIAL CELL GKZ BECKMAN COULTER INC. NA

Patients

Seq Age Sex Outcome Treatment
1 82 YR