MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a health professional,user faci report with the FDA on 2017-07-03 for DADE ACTIN ACTIVATED CEPHALOPLASTIN REAGENT 10445711 manufactured by Siemens Healthcare Diagnostics Products Gmbh.
[78997936]
Siemens healthcare diagnostics inc. (siemens) determined that the cause of the unexpectedly low activated partial thromboplastin time (aptt) result was due to the operator's use of the incorrect reagent (actin activated cephaloplastin). The sysmex ca-1500 coagulation analyzer was set up for the actin fsl reagent detector and the operator mistakenly used the actin activated cephaloplastin reagent. The operator has been using the incorrect actin activated cephaloplastin reagent since (b)(6) 2017 and it is unknown when they started using the correct actin fsl reagent. Based on the data provided by the operator, siemens determined that the operator performed a parallel study on the internal quality control between actin activated cephaloplastin and actin fsl reagents. There was a significant difference of approximately 25% in the internal quality controls between the reagents. Internal quality control level 1 recovered within range while internal quality control level 3 recovered low with the incorrect actin activated cephaloplastin reagent. The actin activated cephaloplastin (actin) reagent is less sensitive to heparin, lupus and factors than the actin fsl reagent. Results obtained using the actin reagent, in the heparin therapeutic range, are expected to be lower than the results obtained using actin fsl reagent. Unless a new reference interval is established, it is possible that functional factor defects (viii, ix, xi, xii) or lupus anticoagulants could be missed. Aptt is not a calibrated assay and it is reported in raw seconds. Change of reagent lot or type requires re-establishment of normal and therapeutic ranges to ensure accurate interpretation of results. According to the operator, the wrong reagent was used to run patient samples. The operator indicated that they switched back to the correct reagent- actin fsl reagent. The operator stated that one corrected report was issued and no other samples were questioned by physician(s). Mdr 9610806-2017-00069 was filed for the same event. The instrument and the reagents are performing according to specifications. No further evaluation of this device is required.
Patient Sequence No: 1, Text Type: N, H10
[78997937]
An unexpectedly low activated partial thromboplastin time (aptt) result of 55. 8 seconds was obtained on a patient sample (specimen (b)(6)) on the sysmex ca-1500 analyzer using the actin activated cephaloplastin reagent. The aptt result of 55. 8 seconds was reported to the physician, who questioned the result. The operator stated that there was a user error since they ran patient samples using the actin activated cephaloplastin reagent while the sysmex ca-1500 analyzer was set up for the actin fsl reagent detector. The patient blood was re-drawn and run on the same sysmex ca-1500 analyzer using the correct actin fsl reagent and an aptt result of 85 seconds was obtained. The re-run result was reported to the physician. The operator's aptt reference range is 21. 8-31. 5 seconds. There are no reports of patient intervention or adverse health consequences due to the unexpectedly low activated partial thromboplastin time (aptt) result.
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 9610806-2017-00066 |
| MDR Report Key | 6684272 |
| Report Source | HEALTH PROFESSIONAL,USER FACI |
| Date Received | 2017-07-03 |
| Date of Report | 2017-07-03 |
| Date of Event | 2017-06-07 |
| Date Mfgr Received | 2017-06-08 |
| Date Added to Maude | 2017-07-03 |
| Event Key | 0 |
| Report Source Code | Manufacturer report |
| Manufacturer Link | Y |
| Number of Patients in Event | 0 |
| Adverse Event Flag | 3 |
| Product Problem Flag | 3 |
| Reprocessed and Reused Flag | 3 |
| Health Professional | 3 |
| Initial Report to FDA | 3 |
| Report to FDA | 3 |
| Event Location | 3 |
| Manufacturer Contact | ELIZABETH BERNASCONI |
| Manufacturer Street | 511 BENEDICT AVE |
| Manufacturer City | TARRYTOWN NY 10591 |
| Manufacturer Country | US |
| Manufacturer Postal | 10591 |
| Manufacturer Phone | 9145242495 |
| Manufacturer G1 | SIEMENS HEALTHCARE DIAGNOSTICS PRODUCTS GMBH |
| Manufacturer Street | EMIL-VON-BEHRING-STR. 76 |
| Manufacturer City | MARBURG, D-35041 |
| Manufacturer Country | GM |
| Manufacturer Postal Code | D-35041 |
| Single Use | 3 |
| Previous Use Code | 3 |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | DADE ACTIN ACTIVATED CEPHALOPLASTIN REAGENT |
| Generic Name | DADE ACTIN ACTIVATED CEPHALOPLASTIN REAGENT |
| Product Code | GFO |
| Date Received | 2017-07-03 |
| Model Number | DADE ACTIN ACTIVATED CEPHALOPLASTIN REAGENT |
| Catalog Number | 10445711 |
| Lot Number | 557231 |
| Device Expiration Date | 2018-10-20 |
| Operator | HEALTH PROFESSIONAL |
| Device Availability | N |
| Device Eval'ed by Mfgr | N |
| Device Sequence No | 1 |
| Device Event Key | 0 |
| Manufacturer | SIEMENS HEALTHCARE DIAGNOSTICS PRODUCTS GMBH |
| Manufacturer Address | EMIL-VON-BEHRING- STR. 76 MARBURG, D-35041 GM D-35041 |
| Patient Number | Treatment | Outcome | Date |
|---|---|---|---|
| 1 | 0 | 2017-07-03 |