FDA Adverse Event Malfunction Summary report: N

DIMENSION VISTA(R) CLINICAL CHEMISTRY SYSTEM

MDR report key: 3605063 · Received February 4, 2014

Report

Report Number
2517506-2014-00020
Event Type
Malfunction
Date Received
February 4, 2014
Date of Event
October 1, 2013
Report Date
January 9, 2014
Manufacturer
SIEMENS HEALTHCARE DIAGNOSTICS INC - GLASGOW
Product Code
JIX
PMA / PMN Number
K061923
Removal / Correction Number
2517506-01-16-2014-001-C
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
MS, US
Reporter Occupation
MEDICAL TECHNOLOGIST

Narratives

Additional Manufacturer Narrative · 1

SIEMENS HEALTHCARE DIAGNOSTICS HAS CONFIRMED COMPLAINTS REGARDING QUALITY CONTROL (QC) SHIFTS WITH PSEUDOCHOLINESTERASE (PCHE) AND IMPRECISION DURING PCHE CALIBRATION WITH DIMENSION VISTA® ENZYME 1 CALIBRATOR (ENZ 1 CAL) LOTS 3FD034 AND 3HD012. INVESTIGATION BY SIEMENS CONFIRMS A LOSS OF PCHE ACTIVITY IN THE AFFECTED LOTS OF ENZYME 1 CALIBRATOR, CAUSING AN ELEVATION OF QC BY AS MUCH AS 80% AND IN SOME INSTANCES, IMPRECISION OF REPLICATES DURING CALIBRATION. QC WILL DETECT ELEVATED PCHE RESULTS FOLLOWING CALIBRATION, AND IN THESE CASES NO PATIENT RESULTS WILL BE REPORTED. SIEMENS ISSUED AN URGENT MEDICAL DEVICE CORRECTION COMMUNICATION (B)(4 )TO CUSTOMERS WHO HAD ORDERED THESE LOTS ADVISING THEM TO DISCONTINUE THE USE OF LOTS 3FD034 AND 3HD012 TO CALIBRATE PCHE. DIMENSION VISTA® ENZ 1 CAL (CATALOG # KC310) LOTS 3FD034 AND 3HD012 CAN BE USED TO CALIBRATE THE OTHER ANALYTES LISTED IN THE IFU: AMYLASE (AMY), GAMMA-GLUTAMYL TRANSFERASE (GGT), LACTATE DEHYDROGENASE (LDH), AND LIPASE (LIPL). SIEMENS HAS CONFIRMED ACCEPTABLE PERFORMANCE OF THESE ENZYMES WITH LOTS 3FD034 AND 3HD012.

Description of Event or Problem · 1

THE ACCOUNT REPORTED A QC SHIFT HIGH AFTER CALIBRATION OF THE PSEUDOCHOLINESTERASE (PCHE) REAGENT WITH DIMENSION VISTA(R) ENZ I CALIBRATOR KC310, LOT 3FD034. RECOVERIES ABOVE LABORATORY RANGES WERE ALSO OBTAINED WITH ENZ I CALIBRATOR LOT 3HD012. IT IS UNKNOWN IF PATIENT RESULTS WERE REPORTED WHILE QC WAS OUT OF RANGE. IT IS UNKNOWN IF PATIENT TREATMENT WAS ALTERED OR PRESCRIBED ON THE BASIS OF FALSELY ELEVATED PCHE RESULTS. THERE WAS NO REPORT OF ADVERSE HEALTH CONSEQUENCES AS A RESULT OF THE FALSELY ELEVATED PCHE RESULTS.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
72996 DIMENSION VISTA(R) CLINICAL CHEMISTRY SYSTEM ENZYME 1 CALIBRATOR JIX SIEMENS HEALTHCARE DIAGNOSTICS INC - GLASGOW 3FD034

Patients

Seq Age Sex Outcome Treatment
1