Agfa submitted mdr report #1225058-2010-00001 to the fda on june 7, 2010, for a site in the us.A 14th occurrence is being reported for the same issue/same device: impax cv results management administration tool (rmat).This is an internal discovery determined during the implementation of the associated problem correction plan, rmat verification, as reported in fda z-2112-10.Within this occurrence are 1490 different study dates in which an individual mdr report will be submitted for each associated study date and medical record number/s (mrn) identified.
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An agfa clinical analyst performed a retro-analysis and reported the findings to agfa service and agfa product quality manager.Agfa¿s investigation into this occurrence of rmat customizations has revealed that this specific change had the potential to introduce clinical inaccuracies in pt reports.Specifically: the original sentence finding of: ¿the mitral valve leaflets appear normal¿ has been changed to: ¿there is partial rupture of the anterolateral papillary muscle¿.In this issue, the original sentence states the mitral valve leaflets are normal.The sentence change however, contains clinically different content indicating the presence of anterolateral papillary muscle rupture.This could lead to incorrect diagnosis and or inappropriate treatment as a papillary muscle rupture would indicate the presence of mitral regurgitation and may indicate the need for mitral valve leaflet repair.If this sentence change is found in the production environment, the ca believes that the potential for misdiagnosis is greater than the potential for inappropriate treatment as the referring surgeon would assess the images prior to intervention.Potential impact: if the change was made after reports had been generated with the original sentence selected, those reports prior to the change could display incorrect clinical data if viewed in rm or if used as a template for a repeat study on that pt.There has been no reported pt harm for this occurrence.A reportable correction is underway for this issue and has been reported to the fda via reference # z-2112-10.Agfa will follow the rmat post market verification work instructions to correct the sentence finding.Any further investigation for the site described in this report will be documented in the ongoing cfr part 806 reporting.(b)(6).
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