FDA Adverse Event Malfunction Summary report: N

BACT/ALERT MP - 419744

MDR report key: 9418327 · Received December 5, 2019

Report

Report Number
3002769706-2019-00067
Event Type
Malfunction
Date Received
December 5, 2019
Report Date
October 14, 2020
Manufacturer
BIOMERIEUX INC.
Product Code
MDB
UDI-DI
03573026506063
PMA / PMN Number
K190405
Product Problem
Yes
Report Source
Manufacturer report
Reporter Location
EI
Reporter Occupation
OTHER HEALTH CARE PROFESSIONAL

Narratives

Additional Manufacturer Narrative · 0

A CUSTOMER IN IRELAND NOTIFIED BIOMÉRIEUX OF OBTAINING TWENTY SEVEN (27) FALSE POSITIVE RESULTS FROM TWENTY-TWO (22) SEPARATE PATIENTS WHILE USING BACT/ALERT® MP BOTTLE (REF. 419744, LOT 1051733). THE FLAGGED POSITIVE BOTTLES WERE SUBCULTURED AND SMEARED (GRAM STAIN). THE SMEAR AND SUBCULTURE FOR ALL IMPACTED BOTTLES WERE NEGATIVE. IN RESPONSE TO THE CUSTOMER COMPLAINT, BIOMÉRIEUX CONDUCTED AN INTERNAL INVESTIGATION. EVALUATION OF THE DEVICE RECORDS ASSOCIATED WITH BACT/ALERT® MP BOTTLE LOT 1051733 IDENTIFIED THAT NO ANOMALIES WERE NOTED. ADDITIONALLY, LOT 1051733 MET FINAL AQL VISUAL INSPECTION ACCEPTANCE CRITERIA. PRODUCT RETAINS OF BACT/ALERT® MP BOTTLE LOT 1051733 WERE NOT REQUESTED FOR TESTING AS THE LOT WAS EXPIRED AT THE TIME OF THE COMPLAINT. THE ROOT CAUSE OF THE FALSE POSITIVE RESULTS OBTAINED BY THE CUSTOMER COULD NOT BE DETERMINED DUE TO INSUFFICIENT INFORMATION. NO BOTTLE GRAPHS, STORAGE DETAILS, ANSWERS TO QUESTIONS, SAMPLE SOURCES, PROCESSING METHOD/PROCEDURE, OR INSTRUMENT BACKUP WERE PROVIDED. THE INVESTIGATION CONFIRMED THE OCCURRENCE OF FALSE POSITIVE BOTTLES IS A KNOWN RISK; THE IMPACT TO THE PATIENT IS VERY LOW AS THE CONFIRMATORY SMEAR AND SUBCULTURE WILL SHOW IF ORGANISMS ARE PRESENT. THE INSTRUCTION TO SMEAR AND SUBCULTURE POSITIVE BOTTLES IS PRESENT IN THE BACT/ALERT® 3D USER MANUAL. SEE SECTION H10.

Additional Manufacturer Narrative · 1

THE DEVICE WAS NOT RETURNED TO THE MANUFACTURER.

Description of Event or Problem · 1

A CUSTOMER IN IRELAND NOTIFIED BIOMÉRIEUX OF OBTAINING TWENTY SEVEN (27) FALSE POSITIVE RESULTS FROM TWENTY-TWO (22) SEPARATE PATIENTS WHILE USING BACT/ALERT® MP BOTTLE (REF. 419744, LOT 1051733). BIOMÉRIEUX CUSTOMER SERVICE HAS REQUESTED LAB REPORTS AS WELL AS INFORMATION ABOUT THE TECHNIQUE USED BY THE CUSTOMER FOR SAMPLE/BOTTLE HANDLING. AT THE TIME OF THIS ASSESSMENT THE CUSTOMER HAS NOT PROVIDED THIS INFORMATION. THERE IS NO INDICATION OR REPORT FROM THE LABORATORY THAT THE FALSE POSITIVE RESULTS LED TO ANY ADVERSE EVENT RELATED TO THE PATIENT'S STATE OF HEALTH. BIOMÉRIEUX WILL INITIATE AN INTERNAL INVESTIGATION.

Devices

Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
1211922 BACT/ALERT MP - 419744 BACT/ALERT MP - 419744 MDB BIOMERIEUX INC. 1051733 03573026506063

Patients

Seq Age Sex Outcome Treatment
1