MAUDE Adverse Event Report: NOVA BIOMEDICAL CORP STATSTRIP GLUCOSE HOSPITAL METER; BLOOD GLUCOSE METER

Model Number 54794

Device Problem Patient Data Problem (3197)

Patient Problem Insufficient Information (4580)

Event Date 02/21/2021

Event Type  malfunction  

Manufacturer Narrative

The customer is located in (b)(6) where the meter part number is 54794.As the manufacturer, a similar device part number for the us to report is 54790.Therefore, this report is being submitted to the fda under 54790 and the subsequent report to (b)(6) will reflect 54794.There was no report of patient harm or any intervention required.A device history record (dhr) review has beed requested.Nova is requesting additional information, and further details will be provided in a supplemental report.

Event Description

The customer reported an incorrect patient account number shown when scanned by the statstrip (1.86) meter.This occurred on (b)(6) 2021.Unfortunately, the facility could not determine which patient chart sticker was used when this incident occurred.The customer states they are unaware of any potential patient harm from the barcode misread and will not be returning the meter as it is currently in use at the facility.

Manufacturer Narrative

Udi: (b)(4).The facility reported the meter scanned a patient barcode on the patient chart because the armband would not scan.The chart barcode did not register the correct patient.The initial reporter stated there was no way to determine which barcode was scanned at the time of reporting.They did not report any patient harm or intervention.The facility is continuing to utilize the meter, therefore; no sample was returned to nova for evaluation.A device history record (dhr) review for the meter was performed.The review included an assessment of the production, testing, and release of the products.No abnormalities or concerns were observed; the dhr indicated the released product met all specifications.Previously opened and investigated incidents from the customer facility determined the root cause for the patient misreads is attributed to the user facility using poor quality 1d barcodes that were printed using code -39 symbology.Code-39 is no longer industry standard and has a higher substitution failure rate than code-128 and much higher than the standard 2d barcodes available.This failure mode does not represent a systemic issue or a failure of the meter to perform as intended.The failure mode is directly related to the quality of the barcode being generated by the customer.The root cause of the misread is most likely due to poor barcode quality.Based on the original investigation, nova suggested to prevent barcode mis-reads in the future, the customer should change from a 1d to a 2d barcode, which would greatly reduce the chances of a barcode misread.Trending will be monitored for this and or similar complaints.

• Brand Name: STATSTRIP GLUCOSE HOSPITAL METER
• Type of Device: BLOOD GLUCOSE METER
• Manufacturer (Section D): NOVA BIOMEDICAL CORP; 200 prospect street; waltham MA 02454 9141
• MDR Report Key: 11437408
• MDR Text Key: 267900874
• Report Number: 1219029-2021-00003
• Device Sequence Number: 1
• Product Code: PZI
• UDI-Device Identifier: 00385480547901
• UDI-Public: 00385480547901
• Combination Product (y/n): N
• PMA/PMN Number: K181043
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: company representative,foreig
• Type of Report: Initial,Followup
• Report Date: 03/22/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 03/08/2021
• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: 54794
• Device Catalogue Number: 54790
• Was Device Available for Evaluation?: No
• Date Manufacturer Received: 03/08/2021
• Is This a Reprocessed and Reused Single-Use Device?: No
• Patient Sequence Number: 1