MAUDE Adverse Event Report: SYSMEX CORPORATION SYSMEX PS-10; PS-10 SAMPLE PREPARATION SYSTEM

Catalog Number	BQ716341
Medical Device Problem Code	Computer Software Problem (1112)
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	01/08/2025
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The clinical application specialist (cas) of automated pipetting system ps-10, serial number (b)(6) reported on (b)(6) 2025 that the device missed wash steps between aspirations of antibodies.No erroneous results were reported.There was no report of serious injury or death due to the event.On 12/12/2024 it was confirmed that a software defect had been introduced with ps-10 software version 1.5 and also manifested in software version 1.6.Versioning down to software version 1.4 resolves the issue.On 1/14/2025 a technical product manager confirmed the software defect caused the event reported for ps-10 sn (b)(6).The ps-10 is an open system where a variety of antibody reagent vials may be used for sample preparation.Omission of the probe wash step and potential antibody carry-over may lead to possible erroneous representation of antigen markers in a sample and thus, generate erroneous results in subsequent flow cytometry analysis.If the incorrect result is overlooked and reported, it may lead to misdiagnosis and incorrect treatment.The risk to health is determined by the user's application in flow cytometry analysis, the intended purpose of the clinical test.No warning is issued by the device to alert the operator of the missed wash sequence.No misdiagnosis and/or incorrect treatment have been reported.Sysmex america incorporated, sai, became aware of the product problem on 12/17/2024.On 12/23/2024, sysmex corporation japan (s-corp), the legal manufacturer of the ps-10, initiated a field corrective action (fca) 2422.On 1/6/2025, sai released product notification (pn) cf-07577 to customers and initiated sai field corrective action (fca) 2024-004-c.This event is deemed reportable to the fda due to a product problem, ps-10 software version 1.5 and software version 1.6 software defect, causing missed wash sequences affecting subsequent flowcytometry result accuracy, where an fca is being performed to prevent the risk of harm to patients.
Event or Problem Description
A software defect was identified in sample preparation system ps-10 serial number (sn) (b)(6) software version 1.5, where omission of the probe wash step and potential antibody carry-over may lead to possible erroneous representation of antigen markers in a sample and thus generate erroneous results in subsequent flow cytometry analysis.There has been no report of incorrect treatment, serious injury or death due to the product problem.

• Brand Name: SYSMEX PS-10
• Common Device Name: PS-10 SAMPLE PREPARATION SYSTEM
• Manufacturer (Section D): SYSMEX CORPORATION; 1-5-1 wakinohama-kaigandori; chuo-ku; kobe, hyogo 65100 73; JA 6510073
• Manufacturer (Section G): SYSMEX CORPORATION; 1-5-1 wakinohama-kaigandori; chuo-ku; kobe, hyogo 65100 73; JA 6510073
• Manufacturer Contact: william haste ; 577 aptakisic road; lincolnshire, IL 60069 ; 2245439459
• MDR Report Key: 21322948
• Report Number: 1000515253-2025-00004
• Device Sequence Number: 8485403
• Product Code: PER
• UDI-Device Identifier: 04987562501908
• UDI-Public: (01)04987562501908(11)220328
• Combination Product (Y/N): N
• Initial Reporter State: IL
• Initial Reporter Country: US
• PMA/510(K) Number: EXEMPT
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Health Professional,Company Representative
• Initial Reporter Occupation: Other Health Care Professional
• Remedial Action: Notification,Recall
• Type of Report: Initial
• Report Date (Section B): 02/06/2025

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 Catalogue Number: BQ716341
• Was Device Available for Evaluation?: Yes
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 01/08/2025
• Initial Report FDA Received Date: 02/06/2025
• Was Device Evaluated by Manufacturer? (Y/N): Yes
• Date Device Manufactured: 04/22/2022
• 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
• Usage of Device: Reuse
• Patient Sequence Number: 1
• Outcome Attributed to Adverse Event: Other
• Patient Sex: Unknown