ARCHITECT TOTAL T3
Report
- Report Number
- 3005094123-2014-00063
- Event Type
- Malfunction
- Date Received
- September 24, 2014
- Date of Event
- August 9, 2014
- Report Date
- August 10, 2014
- Manufacturer
- A.I.D.D LONGFORD
- Product Code
- CDP
- PMA / PMN Number
- K983439
- Removal / Correction Number
- 3005094123-09/16/14-001-
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- KS
- Reporter Occupation
- HEALTH PROFESSIONAL
Narratives
CORRECTION AND OR REMOVAL REPORTING NUMBER IS 3005094123-09/16/14-001-R. (TEST RESULT); (NO CONSEQUENCES OR IMPACT TO PATIENT); (INCORRECT OR INADEQUATE TEST RESULT); (HIGH TEST RESULTS). FURTHER ANALYSIS OF THE DATA INDICATES THE REDUCED RLU VALUES ARE EVIDENT FOR MICROPARTICLE BOTTLES SEQUENTIALLY NUMBERED FROM (B)(4) ONWARDS. THESE BOTTLES ARE DERIVED FROM THE LATTER 17% OF THE MICROPARTICLE FILL (TOTAL LOT SIZE: (B)(4) BOTTLES). THE INVESTIGATION HAS DETERMINED THAT 17% OF THE TWO IMPACTED REAGENT LOTS (38901UI00 AND 38901UI01) MAY EXHIBIT LOWER RELATIVE LIGHT UNITS (RLUS) THAN EXPECTED, WHICH IN TURN MAY RESULT IN CONTROLS OUT OF RANGE OR PATIENT RESULTS HIGHER THAN EXPECTED. INTERNAL TESTING OF FILE SAMPLES CONFIRMED THE CUSTOMERS OBSERVATION AND IT WAS DETERMINED THAT THE REDUCTION IN RLUS WAS RELATED TO THE EXISTENCE OF REDUCED PERCENT SOLIDS FROM THIS PORTION OF THE FILL. FOUR POSSIBLE UTILISATION SCENARIOS WITH THE IMPACTED REAGENT MAY BE OBSERVED: THE CUSTOMER CALIBRATES WITH A NOMINAL SOLIDS BOTTLE AND GENERATES RESULTS FROM THE CURVE USING A NOMINAL SOLIDS BOTTLE. NO IMPACT WILL OCCUR. THE CUSTOMER CALIBRATES WITH A NOMINAL SOLIDS BOTTLE AND LATER GENERATES RESULTS FROM THAT CURVE USING A LOW SOLIDS BOTTLE. THIS WILL RESULT IN A POSITIVE BIAS WHEN COMPARED TO SCENARIO 1. THE CUSTOMER CALIBRATES WITH A LOW SOLIDS BOTTLE AND LATER GENERATES RESULTS FROM THAT CURVE USING A NOMINAL SOLIDS BOTTLE. THIS WILL RESULT IN A NEGATIVE BIAS WHEN COMPARED TO SCENARIO 1. THE CUSTOMER CALIBRATES WITH A LOW SOLIDS BOTTLE AND GENERATES RESULTS FROM THAT CURVE USING A LOW SOLIDS BOTTLE. THIS WILL RESULT IN A POSITIVE BIAS WHEN COMPARED TO SCENARIO 1. THE CORRECTION ACTIONS INCLUDED: INTERNAL INTERIM ACTION: ADDITIONAL VERIFICATIONS HAVE BEEN INTRODUCED DURING FILLING PROCESS TO RECORD INFORMATION SUCH AS ACTUAL BOTTLE NUMBERS TESTED AND MIX SPEEDS PRIOR TO TRANSFER. QUALITY HOLD FOR THE AFFECTED REAGENT LOTS WAS ISSUED. A FIELD SAFETY CORRECTIVE ACTION (FSCA) IS PROPOSED FOR ISSUE TO ALL CUSTOMERS TO INFORM THEM OF THE EVENT AND INSTRUCT THEM TO: DISCONTINUE USAGE OF ARCHITECT TT3 REAGENT, LN 7K64-20, LOT 38901UI00 AND LN 7K64-25, LOT 38901UI01. (ALTERNATE IS TO ONLY DESTROY IMPACTED BOTTLES BASED ON SERIAL NUMBERS). REVIEW PATIENT RESULTS GENERATED USING THE LOTS ABOVE TO ENSURE ALIGNMENT TO OVERALL CLINICAL STATUS. A QUALITY DIRECTIVE (QD) WITH Q&A WILL BE PROVIDED TO CALL REGISTRATION TO SUPPORT THEM WITH ANY QUERIES IMPACTED CUSTOMERS MAY HAVE. REPLACEMENT INVENTORY ARE AVAILABLE (7K64-20 AND 7K64-25; LOT 41919UI00; EXP: 20-MAY-2015, 7K64-30; LOT 41918UI01; EXP: 20-MAY-2015).
THE CUSTOMER OBSERVED CONTROLS OUT OF RANGE HIGH ON ARCHITECT TOTAL T3. THE CUSTOMER ATTEMPTED TO RE-CALIBRATE BUT THE TOTAL T3 CALIBRATION RLU WAS HALF THE EXPECTED VALUE. THE CUSTOMER CHANGED TO A DIFFERENT LOT OF REAGENT, RE-CALIBRATED, AND THE CONTROLS PASSED. THERE WERE NO PATIENT RESULTS GENERATED. THERE WAS NO REPORTED IMPACT TO PATIENT MANAGEMENT.
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 594951 | ARCHITECT TOTAL T3 | TOTAL T3 | CDP | A.I.D.D LONGFORD | 38901UI00 |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 | ARCHITECT I2000SR ANALYZER, LIST # 03M74-02,| SERIAL # (B)(4) |