MAUDE MDR 1008571

MDR report key
1008571
Report number
1415939-2008-00037
Event key
0
Event type
3
Date of event
2008-02-19
Date received
2008-03-06
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
0
Health professional
3
Initial report to FDA
3
Event location
0

Manufacturer Contact#

Contact
SUDARSHAN HEBBAR, MD, D-3MQC, AP6B
Address
100 ABBOTT PARK ROAD ABBOTT PARK IL 60064 US
Phone
847-847-8479
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1AXSYM DRUGS FOR ABUSE TOXICOLOGY ASSAY DISKAMPHETAMINE TEST SYSTEMABBOTT LABORATORIESMGXNA3D54-08NANYY

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12008-03-060

Event Narratives#

D

Patient 1

THE CUSTOMER STATED THAT VRTX ERROR 002 IN TASK 40 OCCURRED ON THE AXSYM ANALYZER AFTER EDITING THE CUTOFF PARAMETERS FOR AMPHETAMINES. AXSYM SYSTEM SOFTWARE VERSION 8.0 WAS INSTALLED ON THE ANALYZER. NO IMPACT TO PATIENT MANAGEMENT WAS REPORTED.

N

Patient 1

A NEW AXSYM DRUGS OF ABUSE (DOA)/TOXICOLOGY ASSAY DISK (VERSION 8.0) WAS RELEASED CONTAINING AN UPDATED VERSION OF THE AXSYM AMPHETAMINE/METHAMPHETAMINE II ASSAY FILE. THIS FILE WAS CREATED USING AXSYM OFFLINE SOFTWARE VERSION 6.0. WHEN CUSTOMERS ATTEMPTED TO EDIT THE AXSYM AMPHETAMINE/ METH-AMPHETAMINE II POSITIVE AND NEGATIVE INTERPRETATION CUTOFFS AFTER INSTALLING THE UPDATED ASSAY FILE, THEY OBSERVED AN AXSYM SYSTEM VRTX ERROR #002 IN TASK 40 WHEN RUNNING PATIENT SAMPLES. THE VRTX ERROR CAUSES THE INSTRUMENT TO LOCK UP. THROUGH THE ANALYSIS OF EXISTING DATA AND THE PRELIMINARY INVESTIGATION ASSOCIATED WITH THE RISK EVALUATION, THE ROOT CAUSE WAS IDENTIFIED TO BE A CHANGE IN THE AXSYM OFFLINE SOFTWARE. AXSYM OFFLINE SOFTWARE VERSION 6.0 REPLACED VERSION 5.9.0. THE PARAMETERS IN AXSYM OFFLINE SOFTWARE VERSION 5.9.0 CONTAINED 31 CHARACTERS WHILE THE PARAMETERS IN AXSYM OFFLINE SOFTWARE VERSION 6.0 CONTAINED 47. THE OFFLINE SOFTWARE PADS THESE EXTRA FIELDS WITH SPACES. WHEN THE CUSTOMER EDITS THE POSITIVE AND NEGATIVE INTERPRETATION CUTOFFS THE CHARACTERS FROM THESE FIELDS ARE PUSHED INTO THE NEXT FIELDS, THE NEGATIVE RECALCULATION INTERPRETATION FORMULA AND THE POSITIVE INTERPRETATION HOLD OPTION PARAMETERS. WHEN AN AMPHETAMINE RESULT IS GENERATED, THE AXSYM SYSTEM SOFTWARE ATTEMPTS TO INTERPRET THE RESULT. BECAUSE SPACE CHARACTERS HAVE BEEN PUSHED FROM THE POSITIVE AND NEGATIVE INTERPRETATION CUTOFF PARAMETERS INTO THE INTERPRETATION FORMULA AND HOLD OPTION PARAMETERS, THE AXSYM SOFTWARE CANNOT MAKE A DECISION AND THE VRTX ERROR IS GENERATED. ON 01/10/08, THE DOA/TOXICOLOGY ASSAY DISK WAS PUT ON QUALITY HOLD. A NEW DISK WILL BE RELEASED TO THE FIELD USING AXSYM OFFLINE SOFTWARE VERSION 5.9.0. NO LATER THAN 3/31/08, WHICH WILL HAVE ADDRESSED THE ISSUE IN AXSYM OFFLINE SOFTWARE VERSION 6.0. THIS IS THE FINAL REPORT. END OF REPORT.