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A united states (us) customer contacted a siemens customer care center to report a falsely elevated tacrolimus (tac) result was obtained on a patient sample on a dimension exl 200 integrated chemistry system.A siemens customer service engineer (cse) was dispatched to the site.The cse verified all alignments and remeasured transducer voltages.The cse then calibrated the mixers and verified that the cuvette formation was acceptable.While performing mixer alignments the cse found that wash probe 1 was not fully seated and not making contact with the bottom of the vessel.The cse replaced the sample pump panel.The cse ran service methods and ran both levels of quality controls (qc).All results were near the mean and precision was within limits.The cse reseated the ultrasonics backplane connections and installed an ultrasonics board with a modified r71 resistor to increase ultrasonics voltage.The cse performed another precision study and obtained similar or slightly worse results.The cse verified that the sampler and reagent probe 2 (r2) alignments.A decontamination of the analyzer was performed.The cse performed preventative maintenance at the same time.The cse found broken a r2 flush pump syringe.The cse then performed a system check and qc.The results were within range.Siemens is investigating the event.Mdr's 2517506-2026-00006, 2517506-2026-00017, 2517506-2026-00018, 2517506-2026-00019, 2517506-2026-00020, 2517506-2026-00021, 2517506-2026-00022, 2517506-2026-00023, 2517506-2026-00024, 2517506-2026-00025 and 2517506-2026-00026 were filed for the same event.
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The customer reported a falsely elevated tacrolimus (tac) result was obtained on a patient sample on a dimension exl 200 integrated chemistry system.The erroneous result was not reported to the physician(s).The sample was repeated on an alternate instrument.The repeat result was lower than the erroneous results.The repeat result was reported, as the correct results, to the physician(s).There are no known reports of patient intervention or adverse health consequences due to the event.
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