DIMENSION® CLINICAL CHEMISTRY SYSTEM
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
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.
(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.
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 |