HER2 CISH PHARMD KIT SK109

MAUDE Adverse Event Report

MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed with the FDA on 2016-05-23 for HER2 CISH PHARMD KIT SK109 manufactured by Dako Denmark A/s.

Event Text Entries

[45761314] The production team responsible for this product discovered that, due to human error, the wrong titration method was used when producing the probe mix (po1779) for two lots of the product. These lots were released to the market prior to discovery of the error. The error resulted in the dna probe concentration being approximately 4 to 5 times lower than usual for this product. The affected lots of sk109 met final qc acceptance criteria for cish staining performance. However, the lower dna probe concentration could reduce the stability of the dna probe mix and/or reduce the robustness of the staining performance in relation to pre-analytical factors such as tissue fixation and preparation. The error was discovered by the production team on 28-apr-2016. Only one of the lots has been distributed in the us, this is lot 20031683. The other affected lot 20031665 and not been sold in the us but only in the rest of the world. No incidents have been reported by customers, and the likelihood of indirect harm to a patient due to re-biopsy is considered "very unlikely" because (a) the majority of ffpe tissue specimens collected for diagnostic purposes contain sufficient tissue for several separate staining's (i. E. , retests), and (b) the majority of re-biopsy procedures do not lead to serious medical complications. There is no risk of incorrect diagnosis due to false negative or false positive test results. If sk109 is used according to the ifu then normal cells within the tumor tissue section would serve as internal controls for assay failure, and assay failure would have a very high probability of being detected because the expected signals for her2 and cen-17 would not be present in both normal and tumor cells in the tissue sample.
Patient Sequence No: 1, Text Type: D, B5


MAUDE Entry Details

Report Number9610099-2016-00006
MDR Report Key5673955
Date Received2016-05-23
Date of Report2016-05-23
Date of Event2016-04-28
Date Mfgr Received2016-04-28
Device Manufacturer Date2016-02-01
Date Added to Maude2016-05-23
Event Key0
Report Source CodeManufacturer report
Manufacturer LinkY
Number of Patients in Event0
Adverse Event Flag3
Product Problem Flag3
Reprocessed and Reused Flag3
Health Professional3
Initial Report to FDA3
Report to FDA3
Event Location3
Manufacturer ContactMS. MANI SIRAVANTA
Manufacturer Street6392 VIA REAL
Manufacturer CityCARPINTERIA CA 93013
Manufacturer CountryUS
Manufacturer Postal93013
Manufacturer Phone8055665462
Manufacturer G1DAKO DENMARK A/S
Manufacturer StreetPRODUKTIONSVEJ 42
Manufacturer CityGLOSTRUP, 2600
Manufacturer CountryDA
Manufacturer Postal Code2600
Single Use3
Previous Use Code3
Event Type3
Type of Report0

Device Details

Brand NameHER2 CISH PHARMD KIT
Generic NameHER2 CISH PHARMD KIT
Product CodeNYQ
Date Received2016-05-23
Model NumberSK109
Lot Number20031683
OperatorHEALTH PROFESSIONAL
Device AvailabilityY
Device Eval'ed by Mfgr*
Device Sequence No1
Device Event Key0
ManufacturerDAKO DENMARK A/S
Manufacturer AddressPRODUKTIONSVEJ 42 GLOSTRUP, 2600 DA 2600


Patients

Patient NumberTreatmentOutcomeDate
101. Other 2016-05-23

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