MAUDE data represents reports of adverse events involving medical devices. This maude entry was filed from a foreign,health professional,u report with the FDA on 2017-11-01 for BC THROMBIN REAGENT 10446636 manufactured by Siemens Healthcare Diagnostics Products Gmbh.
[91930985]
Siemens healthcare diagnostics investigated the event to determine the cause of the elevated thrombin time (tt) results on the bcs xp systems and determined that the customer was comparing two different methods for tt determination. The customer used the bc thrombin reagent on the bcs xp systems, while they used the test thrombin reagent on the sysmex ca-660 system to obtain tt results on patient samples. Siemens healthcare diagnostics has confirmed that the bc thrombin reagent kit lot 46751 (contains thrombin reagent lot 517468) and kit lot 47184 (contains thrombin reagent lot 517469) produce unexpected prolonged thrombin time (tt) results for expected normal samples, and may recover above the upper limit of normal (< 21 seconds) as stated within the ifu (instruction for use). The investigation by siemens confirmed that the reference range is shifted to an approximately 20% prolonged tt. If the reference range is not adjusted for the current affected lot, this may lead to a higher number of samples requiring follow-up in the case of slightly prolonged tt. There is a potential for misinterpreting unexpected prolonged results as unfractionated (uf) heparin contamination and some other thrombin inhibitors. An urgent field safety notice (ufsn) ph-17-018. A. Ous was sent to outside the us (ous) customers and an urgent medical device correction (umdc) ph17-018. A. Us was sent to us customers in october 2017. The ufsn and umdc remind customers that reference intervals vary from laboratory to laboratory depending on the population, the technique and reagent lot. Therefore, each laboratory must establish its own reference intervals or verify them whenever one or more of the aforementioned variables are changed. The ufsn and udmc also informs customers using the bc thrombin reagent as a screening assay for thrombin inhibition that the affected lots are more sensitive with approximately 20% prolonged/elevated tt results. This will lead to an increased rate of results above the reference range if not adjusted. Thus, the ufsn and udmc advise customers to adjust their specific reference ranges as per the application sheet for thrombin time with bc thrombin when changing to a new lot. Mdr 9610806-2017-00124, mdr 9610806-2017-00125, mdr 9610806-2017-00126, and mdr 9610806-2017-00127 were filed for the same event.
Patient Sequence No: 1, Text Type: N, H10
[91930986]
Elevated thrombin time (tt) results were obtained on multiple patient samples on two bcs xp systems using bc thrombin reagent lot 517468 (kit lot 46751). These results were not reported to the physician(s). The same samples were rerun on an alternate sysmex ca-660 system using an alternate test thrombin reagent, resulting lower for most samples. The result obtained on the sysmex ca-660 recovered higher for (b)(6). The results obtained on the sysmex ca-660 system were reported to the physician. Internal quality controls were within range on all systems at the time of event. There are no known reports of patient intervention or adverse health consequences due to the elevated tt results.
Patient Sequence No: 1, Text Type: D, B5
| Report Number | 9610806-2017-00120 |
| MDR Report Key | 6995317 |
| Report Source | FOREIGN,HEALTH PROFESSIONAL,U |
| Date Received | 2017-11-01 |
| Date of Report | 2017-11-01 |
| Date of Event | 2017-07-20 |
| Date Mfgr Received | 2017-10-05 |
| Date Added to Maude | 2017-11-01 |
| 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 | CHRISTINA LAM |
| Manufacturer Street | 511 BENEDICT AVE |
| Manufacturer City | TARRYTOWN NY 10591 |
| Manufacturer Country | US |
| Manufacturer Postal | 10591 |
| Manufacturer Phone | 9145243504 |
| 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 |
| Remedial Action | RC |
| Previous Use Code | 3 |
| Removal Correction Number | 9610806-10/18/2017-003-C |
| Event Type | 3 |
| Type of Report | 3 |
| Brand Name | BC THROMBIN REAGENT |
| Generic Name | BC THROMBIN REAGENT |
| Product Code | GJA |
| Date Received | 2017-11-01 |
| Model Number | BC THROMBIN REAGENT |
| Catalog Number | 10446636 |
| Lot Number | 46751 |
| Device Expiration Date | 2018-09-08 |
| 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 | 2017-11-01 |