MAUDE Adverse Event Report: ROCHE DIAGNOSTICS ELECSYS FT3 III; TOTAL TRIIODOTHYRONINE

Catalog Number	09005803190
Medical Device Problem Codes	High Test Results (2457); Non Reproducible Results (4029)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	06/29/2023
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The ft3 iii reagent lot number used at the customer site's e 601 was requested but not provided.The ft3 iii reagent lot number used at the investigation site's e 601 is 686656 with an expiration date of 01-apr-2024.The patient sample was requested for investigation.
Event or Problem Description
The initial reporter received questionable elecsys tsh assay, elecsys ft4 iii assay, elecsys ft3 iii assay and elecsys ft4 iv assay results from one patient sample tested on the customer's cobas 6000 e 601 with serial number (b)(6) and the investigation site's cobas 6000 e 601 with serial number (b)(6).The initial result was not reported outside of the laboratory.The date of blood sampling was used as the date of event.The reporter suspected abnormal tsh results in the roche assays.They then sent the patient sample to the investigation laboratory and subsequently submitted the patient sample to an outsourced laboratory for further investigation.This mdr is for the ft3 iii v2 assay.Please refer to: mdr with a1.Patient identifier (b)(6) for the tsh assay.Mdr with a1.Patient identifier (b)(6) for the ft4 iii assay.Mdr with a1.Patient identifier (b)(6) for the ft4 iv assay.Please refer to the attachment (b)(6) for the table containing the highlighted questionable results.
Additional Manufacturer Narrative
G4 pma / 510k (premarket numbers) was updated.The patient sample was received for investigation.The investigation confirmed the customer's ft4 iii, ft4 iv and ft3 iii results.The tsh result could not be reproduced.The investigation analyzed the patient samples using research versions of the elecsys ft4 and ft3 assays with an alternative chemical ruthenium label structure (bpru assay versions) for the presence of interference; significantly reduced results were obtained.The results confirmed the presence of an interference factor against the chemical ruthenium (ru) label structure of the assays in the patient sample, causing the falsely elevated ft4 iii, ft4 iv, and ft3 iii results.Product labeling states "in rare cases, interference due to extremely high titers of antibodies to analyte-specific antibodies, streptavidin or ruthenium can occur.These effects are minimized by suitable test design.For diagnostic purposes, the results should always be assessed in conjunction with the patient¿s medical history, clinical examination and other findings." the investigation determined that a ruthenium-interfering factor caused the falsely elevated ft4 iii/iv and ft3 iii results.The cause of the falsely elevated tsh result could not be determined.The investigation did not identify a product problem.

• Brand Name: ELECSYS FT3 III
• Common Device Name: TOTAL TRIIODOTHYRONINE
• Manufacturer (Section D): ROCHE DIAGNOSTICS; 9115 hague road; indianapolis IN 46250 0457
• Manufacturer (Section G): ROCHE DIAGNOSTICS GMBH; sandhofer strasse 116; mannheim (baden-wurttemberg) 68305 ; GM 68305
• Manufacturer Contact: amy nelson ; 9115 hague road; indianapolis, IN 46250
• MDR Report Key: 17552242
• Report Number: 1823260-2023-02650
• Device Sequence Number: 6683965
• Product Code: CDP
• UDI-Device Identifier: 07613336171585
• UDI-Public: 07613336171585
• Combination Product (Y/N): Y
• Initial Reporter Country: JA
• PMA/510(K) Number: EXEMPT
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: Foreign,Health Professional,User Facility
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date (Section B): 12/19/2023

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: 10/01/2023
• Device Catalogue Number: 09005803190
• Device Lot Number: 663936
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 07/20/2023
• Supplement Date Received by Manufacturer: 11/27/2023
• Initial Report FDA Received Date: 08/15/2023
• Supplement Report FDA Received Date: 12/19/2023
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Is the Device Labeled for Single Use? (Y/N): No
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Concomitant Medical Products and Therapy/Usage Dates: ATEZOLIZUMAB; CARBOPLATIN; CORTRIL; PACLITAXEL
• Patient Sex: Male