FDA Adverse Event Malfunction Summary report: N

ROCHE

MDR report key: 7276191 · Received February 15, 2018

Report

Report Number
MW5075318
Event Type
Malfunction
Date Received
February 15, 2018
Report Date
February 14, 2018
Manufacturer
ROCHE
Product Code
GJS
Product Problem
Yes
Report Source
Voluntary report
Reporter Location
CO, US
Reporter Occupation
OTHER HEALTH CARE PROFESSIONAL

Narratives

Description of Event or Problem · 1

WE WERE USING THE COAGUCHEK XS PRO DEVICES IN OUR ANTICOAGULATION CLINICS FOR THE PAST FEW YEARS. IN (B)(6) 2017, WE NOTICED THE COAGUCHEK WAS NO LONGER CORRELATING WITH OUR MAIN LAB INSTRUMENT, THE STAGO COMPACT WITHIN THE CLIA ACCEPTABLE LIMIT OF +/- 0.5 INR. WE CONTACTED ROCHE AND STAGO ABOUT THE PROBLEM AND INVESTIGATED MANY PTS AND QC RECORDS WITH NO ANSWERS. ROCHE INSISTS THE ISSUE IS THE COAGUCHEK AND STAGO DEVICES ARE SO DIFFERENT FROM EACH OTHER THAT THEY CAN'T COMPARE WELL. HOWEVER, MY 6 MONTHS METHOD COMPARISONS WERE FINE BEFORE (B)(6) 2017. I DISCOVERED THAT ANY INR READINGS ON THE COAGUCHEK GREATER THAN 3.0 DID NOT CORRELATED WITHIN THE 0.5 INR TO OUR MAIN LAB STAGO INSTRUMENT. I HAD COMPLAINTS FROM MY PHARMACISTS THAT THEY WERE CHANGING COUMADIN DOSAGE BASED ON THE COAGUCHEK INR ONLY TO FIND OUT LATER THAT THE LAB DRAW WAS MUCH DIFFERENT. THIS WAS LEAVING THEM IN THE POSITION OF HAVING TO ADJUST DOSAGE AGAIN AND CONFUSING THE PTS. THE COAGUCHEK WAS ONLY COMPARING WELL TO THE MAIN LAB UP TO AN INR OF 3.0. ANYTHING GREATER THAN 3.0 WAS INCONSISTENT ACROSS ALL DEVICES, LOCATIONS, PTS AND OPERATORS. DATES OF USE: (B)(6) 2013 - (B)(6) 2017. DIAGNOSIS OR REASON FOR USE: POINT OF CARE INR FOR COUMADIN MONITORING.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
117492 ROCHE COAGUCHEK XS PRO GJS ROCHE 238, 206

Patients

Seq Age Sex Outcome Treatment
1