MAUDE Adverse Event Report: BD KIESTRA LAB AUTOMATION BD KIESTRA¿ INOQULA+¿ TLA; MICROBIAL SPECIMEN INOCULATION/STREAKING INSTRUMENT

Catalog Number 447213

Device Problems Nonstandard Device (1420); Use of Device Problem (1670); Electrical Power Problem (2925); Installation-Related Problem (2965); Patient Data Problem (3197)

Patient Problem No Known Impact Or Consequence To Patient (2692)

Event Date 07/18/2019

Event Type  malfunction  

Manufacturer Narrative

Field correction initiated on 26 july, 2019.Capa# (b)(4) has been opened to further investigate this issue.An anomaly was discovered in inoqula software (b)(4) that had the potential to cause a mismatch between a specimen and plate.The mismatch could happen when the following conditions occur together: inoqula hardware is not operating, such as during a power outage.Pipette has already drawn a specimen waiting to be dispensed on a plate, and user selects the ¿reset¿ function from the system menu.An immediate update to the software was made and validated.All impacted customers were provided with the update and information on any mis-associated data in their system.This was done via a recall and an 806 form was submitted on 5 august, 2019.

Event Description

It was reported that while using a bd kiestra¿ inoqula+¿ tla to process patient urine samples, the customer reported discrepancies in bacterial growth between the blood agar plates and the macconkry agar plates being used for culture after a power outage.During the investigation into this issue, through automated log-file analysis numerous mis-associated plates/specimens were discovered.Customers are being informed about the events, including ids and accession ids that were mis-associated.No erroneous results reported.

Manufacturer Narrative

Correction: the device manufacture date was corrected to 08/11/2018.

Event Description

It was reported that while using a bd kiestra¿ inoqula+¿ tla to process patient urine samples, the customer reported discrepancies in bacterial growth between the blood agar plates and the macconkry agar plates being used for culture after a power outage.During the investigation into this issue, through automated log-file analysis numerous mis-associated plates/specimens were discovered.Customers are being informed about the events, including ids and accession ids that were mis-associated.No erroneous results reported.

• Brand Name: BD KIESTRA¿ INOQULA+¿ TLA
• Type of Device: MICROBIAL SPECIMEN INOCULATION/STREAKING INSTRUMENT
• Manufacturer (Section D): BD KIESTRA LAB AUTOMATION; 6 marconilaan; drachten
• MDR Report Key: 8899027
• MDR Text Key: 180837455
• Report Number: 3010141591-2019-00156
• Device Sequence Number: 1
• Product Code: JTC
• UDI-Device Identifier: 00382904472139
• UDI-Public: 00382904472139
• Combination Product (y/n): N
• PMA/PMN Number: EXEMPT
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: other,user facility
• Remedial Action: Recall
• Type of Report: Initial,Followup
• Report Date: 08/16/2019

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 08/15/2019
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Other
• Device Catalogue Number: 447213
• Was Device Available for Evaluation?: No
• Date Manufacturer Received: 07/18/2019
• Is This a Reprocessed and Reused Single-Use Device?: No
• Removal/Correction Number: 1119779-07/23/2019-004-C
• Patient Sequence Number: 1
• Patient Outcome(s): Other