FDA Adverse Event Malfunction Summary report: N

DIMENSION® CLINICAL CHEMISTRY SYSTEM

MDR report key: 2904316 · Received January 9, 2013

Report

Report Number
2517506-2013-00008
Event Type
Malfunction
Date Received
January 9, 2013
Date of Event
December 11, 2012
Report Date
December 11, 2012
Manufacturer
SIEMENS HEALTHCARE DIAGNOSTICS INC
Product Code
MLM
PMA / PMN Number
K060502
Removal / Correction Number
2517506-11-27-2012-018-C
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
NJ, US
Reporter Occupation
MEDICAL TECHNOLOGIST

Narratives

Additional Manufacturer Narrative · 1

ANALYSIS OF THE INSTRUMENT AND INSTRUMENT DATA INDICATE THAT THE CAUSE FOR THE BIASED LOW TACROLIMUS RESULTS IS UNKNOWN. THE ACCOUNT IS SENDING THEIR TACROLIMUS SAMPLES FOR TESTING AT AN ALTERNATE FACILITY. THE REAGENT ISSUE IS UNDER INVESTIGATION BY SIEMENS HEALTHCARE DIAGNOSTICS INC. THE INSTRUMENT IS PERFORMING WITHIN SPECIFICATIONS. NO FURTHER EVALUATION OF THE DEVICE IS REQUIRED.

Additional Manufacturer Narrative · 1

(B)(4). SIEMENS HEALTHCARE DIAGNOSTICS INC. ISSUED AN URGENT MEDICAL DEVICE RECALL ON 01-15-2013. THE RECALL LETTER CONFIRMED THE COMPLAINT OF LOW QC AND PATIENT SAMPLE RECOVERIES WITH THE DIMENSION TACR FLEX REAGENT CARTIDGE LOT FA3316. THE RECALL LETTER INSTRUCTED CUSTOMERS TO IMMEDIATELY DISCARD ANY REMAINING REAGENT INVENTORY OF LOT FA3316.

Description of Event or Problem · 1

BIASED LOW RESULTS WERE OBTAINED ON TACROLIMUS (TACR) ON QC AND PATIENT SAMPLES IN A LOT CROSSOVER STUDY. THE REAGENT LOT FAILED TO CALIBRATE AND THE REAGENT LOT WAS NOT PUT INTO USE. THE PATIENT RESULTS WERE NOT REPORTED TO THE PHYSICIAN. PATIENT TREATMENT WAS NOT ALTERED OR PRESCRIBED. THERE WAS NO REPORT OF ADVERSE HEALTH CONSEQUENCES AS A RESULT OF THE BIASED LOW TACROLIMUS RESULTS.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
10648 DIMENSION® CLINICAL CHEMISTRY SYSTEM TACROLIMUS (TACR) FLEX® REAGENT CARTRIDGE MLM SIEMENS HEALTHCARE DIAGNOSTICS INC FA3316

Patients

Seq Age Sex Outcome Treatment
1