MAUDE MDR 2132642

MDR report key
2132642
Report number
1823260-2011-03319
Event key
0
Event type
3
Date of event
2011-05-13
Date received
2011-06-17
Adverse event
3
Product problem
3
Patients in event
0
Reporter occupation
0
Health professional
3
Initial report to FDA
3
Event location
3

Manufacturer Contact#

Contact
NA JENNIFER WOLFGRAM
Address
9115 HAGUE ROAD NA INDIANAPOLIS IN 46250 US
Phone
317-317-3175
Report source
M
Manufacturer link flag
Y

Devices#

Seq, Brand, Generic table
SeqBrandGenericManufacturerProduct codeModelCatalogLotPMA510(k)ImplantEvaluatedAvailability
1ETHYL ALCOHOLNAD-NADH, SPECIFIC REAGENT FOR ALCOHOL ENZYME METHODROCHE DIAGNOSTICSDMLNA11868152190ASKUR N

Patients#

Sequence, Received, Treatment table
SequenceReceivedTreatmentOutcome
12011-06-170

Event Narratives#

D

Patient 1

THE USER RECEIVED QUESTIONABLE ETHANOL RESULTS FOR ONE PATIENT SAMPLE FROM THE ANALYTICAL P MODULE SERIAL NUMBER (B)(4). THE RESULTS WERE -10 MG/L, -6 MG/L AND 148 MG/L. THE RESULT OF 148 MG/L WAS REPORTED OUTSIDE THE LABORATORY. ON (B)(6) 2011, THE CUSTOMER RETESTED THE SAMPLE WITH MANUAL DILUTIONS. THE RESULTS WITH A 1:10 DILUTION WERE -1.6 MG/L AND -1.7 MG/L. THE RESULT WITH A 1:50 DILUTION WAS 0.6 MG/L. THE PATIENT CLAIMED TO HAVE NOT DRUNK ANY ALCOHOL AND WAS REMOVED FROM A LIVER TRANSPLANT LIST. THE USER BELIEVED THE RESULT OF 148 MG/L WAS GENERATED WHEN THE SAMPLE WAS INADVERTENTLY TESTED WITH A 1:50 DILUTION THAT HAD BEEN PROGRAMMED FOR A PREVIOUS SAMPLE.

N

Patient 1

THIS EVENT OCCURRED IN (B)(6).

N

Patient 1

ADDITIONAL INFORMATION WAS RECEIVED STATING THE SAMPLE IN QUESTION WAS TESTED BY GC-MS (GAS CHROMATOGRAPHY-MASS SPECTROSCOPY) AND THE RESULT WAS NEGATIVE FOR ETHANOL.

N

Patient 1

ADDITIONAL INFORMATION WAS RECEIVED PROVIDING UPDATED INFORMATION FOR THE FOLLOWING MEDWATCH FIELDS: DATE OF BIRTH WAS (B)(6) AND AGE AT TIME OF EVENT WAS (B)(6). SEX WAS MALE. RELEVANT TESTS/LABORATORY DATA, INCLUDING DATES: THE ETHANOL RESULT FROM (B)(6) 2011 WAS

N

Patient 1

AFTER FURTHER INVESTIGATION, THE SPECIFIC ROOT CAUSE COULD NOT BE DETERMINED. FURTHER INVESTIGATION WAS NOT POSSIBLE DUE TO MISSING INFORMATION. IT WAS SUSPECTED A DILUTION FACTOR FOR A PREVIOUS SAMPLE COULD HAVE COULD HAVE BEEN APPLIED TO THIS SAMPLE IF THE USER DID NOT CONFIRM THE REMOVAL OF THE DILUTION IN THE TEST SELECTION SCREEN. THE PATIENT DID NOT RECEIVE ANY TREATMENT AND DID NOT LOSE ANY TREATMENT DUE TO THE EVENT. THE TAKING OF BLOOD SAMPLES AND THE TESTING TO PROVE ABSTINENCE OF ALCOHOL SHOULD BE DONE ONLY BY WELL TRAINED PERSONNEL AND IN CASE OF POSITIVE TESTING THE SAMPLE SHOULD BE IMMEDIATELY RETESTED, ALL CONDITIONS - AS IN THIS CASE, A DILUTION FACTOR FOR A PREVIOUS (OTHER) SAMPLE COULD HAVE TAKEN OVER BY NOT VERIFYING THE "SAMPLE VOLUME/DILUTION" IN TEST SELECTION SCREEN - ARE TO BE CONTROLLED BEFORE THE POSITIVE TESTING IS REPORTED OUT OF LABORATORY.