MAUDE Adverse Event Report: SIEMENS HEALTHCARE DIAGNOSTICS PRODUCTS GMBH DADE INNOVIN

Model Number	DADE INNOVIN
Medical Device Problem Code	Incorrect, Inadequate or Imprecise Result or Readings (1535)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	12/30/2020
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The customer contacted a siemens customer care center (ccc).Siemens determined that pre-analytical issues (specific sample characteristics, blood collection, transportation, and/or sample processing/handling in the laboratory) potentially contributed to the discordant results.Siemens specialists were previously dispatched to the customer's site to evaluate and discuss pre-analytical handling conditions with the customer.The cause of the event is use error.The reagent is performing according to specifications.No further evaluation of this device is required.
Event or Problem Description
A discordant, falsely elevated prothrombin time (pt) result was obtained on a patient sample on a sysmex cs-5100 system using dade innovin reagent and was flagged with error messages.The sample was also run for prothrombin time percent (pt%) and prothrombin time international normalized ratio (inr) at the same time, but no numeric results were generated.The sample was then repeated for inr, resulting falsely elevated.The same sample was then repeated for pt, inr, and pt% with the same system and reagent.The pt and inr recovered falsely elevated and the pt% recovered falsely low.The same sample was then repeated for pt, inr, and pt% on the same sysmex cs-5100 system but using thromborel s reagent.The pt and inr recovered lower and the pt% recovered higher.The same sample was then repeated for pt, inr, and pt% on an alternate sysmex cs-5100 system using dade innovin reagent.The pt and inr recovered lower than the initial discordant results and the pt% recovered higher than the initial discordant result.The inr result obtained on the alternate sysmex cs-5100 system using dade innovin reagent was reported, as the correct result, to the physician(s).There are no reports of patient intervention or adverse health consequences due to the discordant, falsely elevated prothrombin time (pt) and prothrombin time international normalized ratio (inr) results or the discordant, falsely low prothrombin time percent (pt%) result.

• Brand Name: DADE INNOVIN
• Common Device Name: DADE INNOVIN
• Manufacturer (Section D): SIEMENS HEALTHCARE DIAGNOSTICS PRODUCTS GMBH; emil-von-behring- str. 76; marburg, D-350 41; GM D-35041
• MDR Report Key: 11263106
• Report Number: 9610806-2021-00018
• Device Sequence Number: 3384227
• Product Code: GJS
• UDI-Device Identifier: 00842768003783
• UDI-Public: 00842768003783
• Combination Product (Y/N): N
• Initial Reporter Country: FR
• PMA/510(K) Number: K974343
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: foreign,health professional,u
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 02/01/2021

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
• Operator of Device: Health Professional
• Device Expiration Date: 10/01/2022
• Device Model Number: DADE INNOVIN
• Device Catalogue Number: 10445704
• Device Lot Number: 549761
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 01/05/2021
• Initial Report FDA Received Date: 02/01/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 71 YR