FDA Adverse Event Malfunction Summary report: N

ADVIA CENTAUR XP HCV (AHCV) ASSAY

MDR report key: 9207583 · Received October 18, 2019

Report

Report Number
1219913-2019-00217
Event Type
Malfunction
Date Received
October 18, 2019
Date of Event
October 10, 2019
Report Date
February 13, 2020
Manufacturer
SIEMENS HEALTHCARE DIAGNOSTICS, INC.
Product Code
MZO
UDI-DI
00630414473161
PMA / PMN Number
P030056
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
BR
Reporter Occupation
OTHER HEALTH CARE PROFESSIONAL

Narratives

Additional Manufacturer Narrative · 0

SIEMENS FILED THE INITIAL MDR 1219913-2019-00217 ON OCTOBER 18, 2019. SIEMENS FILED THE MDR 1219913-2019-00217 SUPPLEMENTAL REPORT 1 ON DECEMBER 12, 2019. 12/20/2019 ADDITIONAL INFORMATION: THE CUSTOMER SENT THE PATIENT SAMPLE TO SIEMENS HEALTHCARE DIAGNOSTICS FOR FURTHER TESTING AND INVESTIGATION. THE CUSTOMER RETURNED PATIENT SAMPLE WAS PROCESSED AT N = 2 NEAT USING HCV REAGENT LOTS 062328 (COMPLAINT) AND 062339 (REFERENCE) ON THE ADVIA CENTAUR XP. THE RESULTS WERE NEGATIVE AND WERE CONSISTENT WITH THE CUSTOMER'S FINDINGS. RESULTS (INDEX): REAGENT LOT 062328 RESULTS: 0.54 AND 0.55, REAGENT LOT 062339 RESULTS: 0.49 AND 0.50. SIEMENS HEALTHCARE DIAGNOSTICS IS AWAITING FURTHER INFORMATION FROM THE CUSTOMER. MDR 1219913-2019-00216 SUPPLEMENTAL REPORT 2 WAS FILED FOR THE SAME EVENT.

Additional Manufacturer Narrative · 0

SIEMENS FILED THE INITIAL MDR 1219913-2019-00217 ON OCTOBER 18, 2019. 11/18/2019 ADDITIONAL INFORMATION: A CUSTOMER SERVICE ENGINEER (CSE) REPORT WAS RECEIVED IN NOVEMBER. THE CSE CHECKED THE PIPES OF THE HYDRAULIC SYSTEM, VISUAL PROTOCOL, PIPETTING AND PIPINGS CONFERENCE. NO ERRORS FOUND. THE ENGINEER FOLLOWED THE ROUTINE AND NO ERRORS OCCURRED DURING THE SAMPLING PROCESS. AFTER THE ACTIONS OF THE CSE, THE SIEMENS TECHNICAL APPLICATION SPECIALIST (TAS) RETURNED TO THE CUSTOMER SITE, REPEATED THE SAMPLE, AFTER CENTRIFUGATION AND RESULT CONFIRMED NEGATIVE (INDEX= 0.54). THE PATIENT COMPLAINS ABOUT THIS RESULT BECAUSE HIS PREVIOUS DIAGNOSIS WAS POSITIVE. THE CUSTOMER HAS THE SAMPLE (1ML) FOR SHIPMENT. SIEMENS HEALTHCARE DIAGNOSTICS IS INVESTIGATING. MDR 1219913-2019-00216 SUPPLEMENTAL REPORT 1 WAS FILED FOR THE SAME EVENT.

Additional Manufacturer Narrative · 0

SIEMENS FILED THE INITIAL MDR 1219913-2019-00217 ON (B)(6), 2019. SIEMENS FILED THE MDR 1219913-2019-00217 SUPPLEMENTAL REPORT 1 ON (B)(6) 2019. SIEMENS FILED THE MDR 1219913-2019-00217 SUPPLEMENTAL REPORT 2 ON (B)(6) 2020. (B)(6) , 2020 ADDITIONAL INFORMATION: SIEMENS HAS MADE SEVERAL ATTEMPTS TO GAIN ADDITIONAL INFORMATION FROM THE CUSTOMER. THE SAMPLE WAS TESTED ON BOTH HCV KIT LOTS 328 AND 339. IN BOTH LOTS THE RETURNED SAMPLE RESULTED AS NEGATIVE, 0.55 AND 0.50 INDEX RESPECTIVELY. OTHER METHODS WERE POSITIVE, HOWEVER, THERE WAS NO MEDICAL HISTORY PROVIDED THAT TOLD US WHEN THE PERSON WAS INFECTED AND WHAT THEIR COURSE OF TREATMENT WAS. THERE WAS NO EVIDENCE THAT THE SEND OUT METHODS DID NOT PRODUCE A FALSE POSITIVE RESULT. IN HOUSE KIT DATA WAS REVIEWED AND BOTH KIT LOTS 328 AND 339 MET ALL RELEASE SPECIFICATIONS FOR MEDICAL DECISIONS POOLS, QUALITY CONTROL AND PATIENT POOLS. NO PRODUCT NONCONFORMANCE IDENTIFIED AND THE CUSTOMER HAS NOT REPORTED FURTHER DISCORDANT RESULTS. THE INSTRUMENT IS PERFORMING WITHIN SPECIFICATIONS. NO FURTHER EVALUATION OF THE DEVICE IS REQUIRED. MDR 1219913-2019-00216 SUPPLEMENTAL REPORT 3 WAS FILED FOR THE SAME EVENT.

Additional Manufacturer Narrative · 1

THE CAUSE FOR THE DISCORDANT HCV RESULTS IS UNKNOWN. SIEMENS HEALTHCARE DIAGNOSTICS HAS REQUESTED THE PATIENT SAMPLE FOR FURTHER TESTING AND INVESTIGATION. THE IFU STATES IN THE LIMITATIONS SECTION: "A NEGATIVE TEST RESULT DOES NOT EXCLUDE THE POSSIBILITY OF EXPOSURE TO OR INFECTION WITH HCV. HCV ANTIBODIES MAY BE UNDETECTABLE IN SOME STAGES OF THE INFECTION AND IN SOME CLINICAL CONDITIONS. ASSAY PERFORMANCE CHARACTERISTICS HAVE NOT BEEN ESTABLISHED WHEN THE ADVIA CENTAUR HCV ASSAY IS USED IN CONJUNCTION WITH OTHER MANUFACTURERS' ASSAYS FOR SPECIFIC HCV SEROLOGICAL MARKERS." MDR 1219913-2019-00216 (INITIAL TESTING) WAS FILED FOR THE SAME EVENT.

Description of Event or Problem · 1

A (B)(6) ADVIA CENTAUR XP HCV (AHCV) RESULT WAS OBTAINED FOR A PATIENT SAMPLE. THE RESULT WAS REPORTED AND QUESTIONED BY THE PHYSICIAN BECAUSE THE PREVIOUS HCV RESULT WAS (B)(6). THE SAME PATIENT SAMPLE WAS REPEATED AND THE RESULT WAS (B)(6). THE PATIENT SAMPLE WAS TESTED ON TWO ALTERNATE METHODS AND THE RESULTS WERE (B)(6). A CORRECTED REPORT WAS ISSUED. PATIENT TREATMENT WAS NOT ALTERED OR PRESCRIBED. THERE WAS NO REPORT OF ADVERSE HEALTH CONSEQUENCES DUE TO THE DISCORDANT ADVIA CENTAUR XP HCV RESULT.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1004083 ADVIA CENTAUR XP HCV (AHCV) ASSAY HEPATITIS C VIRUS (ANTI-HCV) ASSAY MZO SIEMENS HEALTHCARE DIAGNOSTICS, INC. N/A 328 00630414473161

Patients

Seq Age Sex Outcome Treatment
1 43 YR