VITROS 350 CHEMISTRY SYSTEM
Report
- Report Number
- 1319681-2017-00105
- Event Type
- Malfunction
- Date Received
- November 13, 2017
- Date of Event
- October 13, 2017
- Report Date
- November 13, 2017
- Manufacturer
- ORTHO-CLINICAL DIAGNOSTICS
- Product Code
- JJE
- Product Problem
- Yes
- Report Source
- Manufacturer report
- Reporter Location
- CA
- Reporter Occupation
- OTHER
Narratives
THE INVESTIGATION DETERMINED THAT A RESULT OBTAINED ON THE VITROS 350 CHEMISTRY SYSTEM FOR A PATIENT SAMPLE WAS MIS-ASSOCIATED WITH THE INCORRECT PATIENT NAME. THE ASSIGNABLE CAUSE OF THE EVENT WAS DETERMINED TO BE USER ERROR AS THE CUSTOMER REUSED A SAMPLE IDENTIFICATION NUMBER (SID) WITHOUT ENSURING THAT THE PREVIOUS SAMPLE PROGRAM FOR THE SID NUMBER WAS PROCESSED TO COMPLETION OR DELETED PRIOR TO USE, AS INSTRUCTED IN THE VITROS 350 OPERATOR'S GUIDE. THE VITROS 350 CHEMISTRY SYSTEM WAS OPERATING AS INTENDED. NO MALFUNCTION OCCURRED.
A CUSTOMER REPORTED THAT AN INCORRECT PATIENT NAME HAD BEEN ASSOCIATED WITH A PATIENT SAMPLE WHEN TESTED ON A VITROS 350 CHEMISTRY SYSTEM. THE FOLLOWING VITROS PRODUCTS WERE IN USE: VITROS 350 CHEMISTRY SYSTEM, SN (B)(4). RESULTS THAT HAVE BEEN ASSOCIATED WITH THE WRONG PATIENT MAY LEAD TO INAPPROPRIATE INTERVENTION WITH THE POTENTIAL FOR SERIOUS INJURY TO THE PATIENT. NO INCORRECT RESULTS WERE REPORTED FROM THE LABORATORY. THERE IS NO ALLEGATION OF PATIENT HARM RELATED TO THIS EVENT THIS REPORT CORRESPONDS TO ORTHO CLINICAL DIAGNOSTICS (ORTHO) INC. (B)(4).
Devices
| Seq | Brand | Generic | Product Code | Manufacturer | Model | Lot | UDI-DI |
|---|---|---|---|---|---|---|---|
| 803067 | VITROS 350 CHEMISTRY SYSTEM | CHEMISTRY ANALYZER | JJE | ORTHO-CLINICAL DIAGNOSTICS |
Patients
| Seq | Age | Sex | Outcome | Treatment |
|---|---|---|---|---|
| 1 |