BEUDAMED
    FDA Adverse Event Malfunction Summary report: N

    C.F.A.S. HBA1C

    MDR report key: 7881186 · Received September 17, 2018

    Report

    Report Number
    1823260-2018-03161
    Event Type
    Malfunction
    Date Received
    September 17, 2018
    Date of Event
    August 29, 2018
    Report Date
    October 3, 2018
    Manufacturer
    ROCHE DIAGNOSTICS
    Product Code
    KRZ
    UDI-DI
    04015630921096
    PMA / PMN Number
    K052101
    Removal / Correction Number
    NA
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    US
    Reporter Occupation
    OTHER HEALTH CARE PROFESSIONAL

    Narratives

    Additional Manufacturer Narrative · 0

    THE INVESTIGATION DID NOT IDENTIFY A PRODUCT PROBLEM. THE CAUSE OF THE EVENT COULD NOT BE DETERMINED.

    Description of Event or Problem · 1

    THE CUSTOMER STATED THAT THEY RECEIVED QUESTIONABLE RESULTS FOR AN UNSPECIFIED NUMBER OF PATIENT SAMPLES TESTED FOR A1C-3 TINA-QUANT HEMOGLOBIN A1C GEN.3 ON A COBAS 6000 C (501) MODULE. THE CUSTOMER PROVIDED DATA FOR ONE PATIENT SAMPLE WHICH HAD AN ERRONEOUS A1C-3 RESULT THAT WAS REPORTED OUTSIDE OF THE LABORATORY. THE COMPLAINED SAMPLE WAS TESTED EACH TIME USING A CALIBRATION FROM A DIFFERENT C.F.A.S. HBA1C CALIBRATOR LOT NUMBER. THIS MEDWATCH WILL APPLY TO CALIBRATOR LOT NUMBER 16006601. PLEASE REFER TO THE MEDWATCH WITH PATIENT IDENTIFIER (B)(6) FOR INFORMATION RELATED TO CALIBRATOR LOT NUMBER 12635800. THE COMPLAINED PATIENT SAMPLE INITIALLY RESULTED WITH AN A1C-3 VALUE OF 11.7 % ON (B)(6) 2018 WHEN USING A CALIBRATION PERFORMED WITH CALIBRATOR LOT 12635800. THIS INITIAL VALUE WAS REPORTED OUTSIDE OF THE LABORATORY. THE CUSTOMER STARTED USING CALIBRATOR LOT NUMBER 16006601 ON (B)(6) 2018. THE FIRST CALIBRATION PERFORMED WITH THIS NEW LOT FAILED. THE CUSTOMER RE-CALIBRATED AND THEN CONTROLS WERE OUTSIDE OF RANGE. THE CUSTOMER CALIBRATED A THIRD TIME AND CONTROLS WERE STILL OUTSIDE OF RANGE. THESE CONTROLS WERE MANUFACTURED BY MAS AND RECOVERY SHIFTED DOWNWARD WITH THE NEW CALIBRATOR LOT. ROCHE CONTROLS WERE TESTED AND THESE WERE WITHIN RANGE AND RIGHT ON THE MEAN. THE CUSTOMER VERIFIED THAT THE CALIBRATOR SET POINTS WERE CORRECT FOR THE NEW CALIBRATOR LOT. THE CUSTOMER PULLED PATIENT SAMPLES THAT WERE TESTED USING A CALIBRATION FROM THE OLDER CALIBRATOR LOT AND REPEATED THESE USING A CALIBRATION PERFORMED WITH THE NEW CALIBRATOR LOT. THE SAMPLES THAT WERE PULLED INCLUDED THE COMPLAINED PATIENT SAMPLE. WHEN TESTED USING THE NEW CALIBRATOR LOT, THE COMPLAINED SAMPLE RESULTED WITH AN A1C-3 VALUE OF 10 % ON (B)(6) 2018. THE CUSTOMER DID NOT KNOW WHICH VALUE FROM THE COMPLAINED SAMPLE WAS CORRECT SINCE ROCHE CONTROLS WERE WITHIN RANGE PRIOR TO EACH RUN OF THE SAMPLE. THE PATIENT WAS NOT ADVERSELY AFFECTED. THE A1C-3 REAGENT LOT NUMBER WAS 317513, WITH AN EXPIRATION DATE OF 30-SEP-2019. THE SERIAL NUMBER OF THE C501 ANALYZER IS (B)(4). THE FIELD SERVICE ENGINEER STATED THAT THE ISSUE WAS RELATED TO THE NEW CALIBRATOR LOT 16006601. HE REPEATED CALIBRATION, MAS CONTROLS, ROCHE CONTROLS, AND RAN PRECISION STUDIES. ROCHE CONTROLS WERE WITHIN RANGE, ON THE MEAN. THE MAS CONTROLS WERE WITHIN RANGE AND WITHIN ONE STANDARD DEVIATION OF THE MEAN. PRECISION STUDIES WERE WITHIN SPECIFICATIONS.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    721128 C.F.A.S. HBA1C CALIBRATOR FOR HEMOGLOBIN AND HEMATOCRIT MEASUREMENT KRZ ROCHE DIAGNOSTICS NA 16006601 04015630921096

    Patients

    Seq Age Sex Outcome Treatment
    1 ASPIRIN 81 MG. CHEWABLE TABLET| ATORVASTATIN (LIPITOR) TABLET| ERGOCALCIFEROL (VITAMIN D) CAPSULE| ERTAPENEM (INVANZ) RECON SOLN| GABAPENTIN (NEURONTIN) CAPSULE| HYDROCODONE-ACETAMINOPHEN (NORCO) TABLET| INSULIN GLARGINE (BASAGLAR KWIKPEN) PEN-INJECTOR| INSULIN LISPRO (ADMELOG) SOLUTION| INSULIN PEN NEEDLE (PEN NEEDLES)| LOSARTAN-HYDROCHLOROTHIAZIDE (HYZAAR) TABLET| METOPROLOL SUCCINATE (TOPROL-XL) TABLET| ONDANSETRON (ZOFRAN-ODT) TABLET DISPERSIBLE| TRAMADOL (ULTRAM) TABLET