MAUDE Adverse Event Report: BIOFIRE DIAGNOSTICS, LLC BIOFIRE® FILMARRAY® GASTROINTESTINAL (GI) PANEL

Model Number RFIT-ASY-0116

Device Problem False Positive Result (1227)

Patient Problem No Clinical Signs, Symptoms or Conditions (4582)

Event Date 02/23/2024

Event Type  malfunction  

Manufacturer Narrative

Investigation: a potential false positive v.Cholerae result on the biofire gi panel was reported after testing a patient stool sample in cary blair transport media on (b)(6) 2024.A repeat test of the sample on the biofire gi panel on the same day did not detect v.Cholerae.The patient was not affected due to the biofire gi panel result as the result was not reported to the physician.No serious injury or death occurred.Conclusion: the investigation determined that the most likely cause of the discrepant v.Cholerae] result was the presence of non-viable organism/nucleic acid in the cary blair transport media.While cary blair medium vials are autoclaved and routinely quality controlled for sterility, non-viable organisms or nucleic acids can remain in the transport medium after the sterilization process.The presence of non-viable organisms and nucleic acid does not compromise the intended use of transport medium, transportation and preservation of clinical stool and rectal specimens; however, the biofire gi panel does not distinguish between nucleic acid from viable or non-viable organisms.The "laboratory precaution" and "limitation" sections of the filmarray gi reagent instruction booklet (https://www.Online-ifu.Com/iti0030) outlines the potential for false positive detections during molecular testing with sterile cary blair transport medium containing detectable levels of non-viable organisms and/or nucleic acid.Importantly, results from the biofire gi panel are intended to be correlated with the clinical history, epidemiological data, and other data available to the clinician evaluating the patient.Detection of organism targets does not imply that the corresponding organisms are infectious or are the causative agents for clinical symptoms.Clinical performance: according to table 11.Biofire gi clinical performance summary of the filmarray gi reagent instruction booklet, the performance claim for the v.Cholerae assay compared to stool culture with standard manual/automated microbiological/biochemical identification showed a specificity of 99.9% (95% ci 99.6-100%).V.Cholerae was detected in the single false positive specimen using bi-directional sequence analysis.To supplement the prospective data, an evaluation of contrived specimens was performed.According to table 18.Biofire gi panel performance using contrived specimens of the filmarray gi reagent instruction booklet, the performance claim for v.Cholerae showed a positive percent agreement (ppa) of 84.6% (95% ci 73.5-92.4%) and a negative percent agreement (npa) of 100% (95% ci 96.7-100%).Ten of the contrived specimens were spiked with an isolate which was found to have a highly divergent toxr gene that was not present in the ncbi database and non-reactive with the biofire gi panel v.Cholerae assay.The biofire gi panel vibrio assay was positive for nine of these specimens.

Event Description

Summary: (b)(6) hospital reported a potential false positive vibrio cholerae result on the biofire® filmarray® gastrointestinal (gi) panel after testing a patient stool sample in cary blair transport media.The patient was not affected due to the biofire gi panel result as the result was not reported to the physician.The investigation determined that the most likely cause of the discrepant v.Cholerae result was the presence of non-viable organism/nucleic acid in the cary blair transport media.

• Brand Name: BIOFIRE® FILMARRAY® GASTROINTESTINAL (GI) PANEL
• Type of Device: BIOFIRE® FILMARRAY® GASTROINTESTINAL (GI) PANEL
• Manufacturer (Section D): BIOFIRE DIAGNOSTICS, LLC; 515 colorow dr; salt lake city UT 84108
• Manufacturer (Section G): BIOFIRE DIAGNOSTICS, LLC; 515 colorow dr; salt lake city UT 84108
• Manufacturer Contact: 515 colorow dr; salt lake city, UT 84108 ; 8017366354
• MDR Report Key: 19001004
• MDR Text Key: 339151785
• Report Number: 3002773840-2024-00295
• Device Sequence Number: 1
• Product Code: PCH
• UDI-Device Identifier: 00815381020109
• UDI-Public: 00815381020109
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K230404
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Health Professional
• Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date: 03/28/2024

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: No
• Is this a Product Problem Report?: Yes
• Device Operator: Health Professional
• Device Model Number: RFIT-ASY-0116
• Device Catalogue Number: RFIT-ASY-0116
• Device Lot Number: 2547423
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Initial Date Manufacturer Received: 02/28/2024
• Initial Date FDA Received: 03/28/2024
• Was Device Evaluated by Manufacturer?: No
• Date Device Manufactured: 10/18/2023
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Patient Age: 87 YR
• Patient Sex: Male