BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    COAGUCHEK ® XS SYSTEM

    MDR report key: 3981852 · Received August 5, 2014

    Report

    Report Number
    1823260-2014-05916
    Event Type
    Malfunction
    Date Received
    August 5, 2014
    Date of Event
    July 15, 2014
    Report Date
    September 3, 2014
    Manufacturer
    ROCHE DIAGNOSTICS
    Product Code
    GJS
    PMA / PMN Number
    K062925
    Removal / Correction Number
    NA
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    CA, US
    Reporter Occupation
    OTHER

    Narratives

    Additional Manufacturer Narrative · 1

    IT WAS UNKNOWN IF THE INITIAL REPORTER SENT REPORT TO THE FDA. IT IS NOT KNOWN WHICH SYSTEM PRODUCED WHICH RESULT. (B)(4).

    Description of Event or Problem · 1

    CALLER STATES THE PATIENT TESTED 6.1 INR ON COAGUCHEK XS SYSTEM 1, AND 6.2 INR ON COAGUCHEK XS SYSTEM 2 WHILE A COMPARISON LAB RETURNED AS 3.9 INR. NO ACTIONS TAKEN BASED ON THE DEVICE RESULT. NO ADVERSE EVENT REPORTED. REQUESTED RETURN OF SUSPECT SYSTEM AND REPLACEMENT WAS SENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    457890 COAGUCHEK ® XS SYSTEM PROTHROMBIN TIME TEST STRIPS GJS ROCHE DIAGNOSTICS NA 29352711

    Patients

    Seq Age Sex Outcome Treatment
    1 062 YR PROSTHETIC LEG| LANTUS| NOVOLOG| COUMADIN