BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    HEMOCUE GLUCOSE 201 MICROCUVETTES

    MDR report key: 3202176 · Received June 28, 2013

    Report

    Report Number
    3003044483-2013-00004
    Event Type
    Malfunction
    Date Received
    June 28, 2013
    Date of Event
    May 30, 2013
    Report Date
    May 30, 2013
    Manufacturer
    HEMOCUE AB
    Product Code
    CGA
    PMA / PMN Number
    K020935
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    KS, US
    Reporter Occupation
    NURSE

    Narratives

    Additional Manufacturer Narrative · 1

    THE LOW MEASUREMENT REPORTED BY THE CUSTOMER WAS ASSESSED TO POTENTIAL POSE A SAFETY RISK IF IT WAS TO REOCCUR. INVESTIGATION: REVIEW OF THE BATCH DOCUMENTATION (DHR): NOTHING REMARKABLE FOUND. TWO PLANNED DEVIATIONS, NOT RELATED TO THE PROBLEM, WERE EFFECTIVE DURING THE TIME OF PRODUCTION ON LOT 1303508. INSPECTION OF SINGLE PACKAGES: THE SINGLE-PACKAGES WERE INSPECTED WITH REGARDS TO MARKS FROM THE KNIFE CUTTING THE DESICCANT. ALL OF THE PACKAGES SHOWN THIS MARKS. VISUAL INSPECTION OF MICROCUVETTES: SOME MICROCUVETTES HAD A DIFFERENT REAGENT DRYING PATTERN THAN NORMALLY. ANALYSIS OF MICROCUVETTES WITH BLOOD: MICROCUVETTES WERE ANALYZED WITH WHOLE BLOOD AND CONTROL MATERIAL. SOME MICROCUVETTES ARE MEASURING TOO LOW COMPARED REFERENCE CUVETTES. CONCLUSION: THE MALFUNCTION FOUND IS DAMAGED SINGLE PACK POUCHES RELATED TO THE PRODUCTION PROCESS. DAMAGED SINGLE PACK POUCHES MAY CAUSE VERY LOW GLUCOSE RESULTS IF POUCHES ARE EXPOSED TO MOISTURE. ACTION TAKEN: REMEDIAL ACTION: THE CUSTOMER HAS BEEN REPLACED WITH CORRECT PRODUCTS AND THE AFFECTED LOT WILL BE WITHDRAWN FROM THE FIELD. CORRECTION: A DESIGN CHANGES WAS IMPLEMENTED IN THE PRODUCTION PROCESS CONSISTING OF A "MECHANICAL RESISTANCE WHEN CUTTING THE DESICCANT IN THE SINGLE PACKAGING PROCESS. CORRECTIVE AND PREVENTIVE ACTIONS ARE HANDLED WITHIN THE HEMOCUE CAPA MANAGEMENT PROCESS.

    Description of Event or Problem · 1

    HEMOCUE AB REC'D A COMPLAINT ON HEMOCUE GLUCOSE 201 FROM A US CUSTOMER. THE HEMOCUE GLUCOSE 201 SYS WAS REPORTED GETTING EXTREMELY LOW READINGS AND GETTING ERROR CODE E70. CONTROLS WERE REPORTED TO BE WITHIN RANGE. THE REPORTED READINGS WERE 15-20 MG/DL AND NO COMPARISON TO OTHER METHODS WAS MADE. NO PT IMPACT WAS REPORTED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    295062 HEMOCUE GLUCOSE 201 MICROCUVETTES LFR: GLUCOSE TEST SYSTEM CGA HEMOCUE AB 110705 1303508

    Patients

    Seq Age Sex Outcome Treatment
    1