Description of Event or Problem · 1
HOSP HAS DISCOVERED A FLAW IN ONE OF ITS LAB ANALYZERS THAT COULD POTENTIALLY CAUSE SIGNIFICANT HARM TO PTS. HOSP HAS CONTACTED THE MFR WITH CONCERNS, HOWEVER IT IS RPTR'S IMPRESSION THAT THEY ARE RELUCTANT TO ADMIT THAT THERE IS A PROBLEM WITH THEIR PRODUCT. HOSP HAS DEVELOPED A WORK-AROUND FOR INSTITUTION BUT RPTR IS CONCERNED THAT REPORTING ERRORS MAY OCCUR AT OTHER LABS. WHEN A SERUM SAMPLE IS ANALYZED FOR QUANTITATIVE HUMAN CHORIONIC GONADATROPIN (PREGNANCY TEST) THE INSTRUMENT MAY REPORT A RESULT AS LESS THAN 0, WHEN IN FACT THERE IS A SUBSTANTIAL AMOUNT OF THE HORMONE PRESENT. THE END RESULT OF THIS COULD BE A FALSE NEGATIVE RESULT REPORTED ON A PREGNANT PT WHO COULD SUBSEQUENTLY BE EXPOSED TO COUNTER INDICATED PROCEDURES. INSTRUMENT TRAINING AND INTERPRETATION OF THE OPERATING MANUALS INDICATE THAT A LESS THAN RESULT IS RELIABLE.