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A customer contacted the ortho clinical diagnostics (ortho) technical solution center (tsc) to report a non-reproducible, higher than expected troponin i result obtained from a single patient sample using vitros troponin i es reagent lot 6385 on a vitros xt 7600 integrated system.Patient sample result of 0.133 ng/ml vs.The expected result of <0.012 ng/ml.Biased results of the magnitude and direction observed may lead to inappropriate physician action if they were to occur undetected.The non-reproducible, higher than expected vitros tropi es result was reported from the laboratory.It is unknown if any treatment was initiated, altered or stopped based on the reported result as the information was not provided upon request.A corrected report was issued for the patient.There was no allegation of patient harm as a result of this event.This report corresponds to ortho clinical diagnostics inc (ortho) complaint number (b)(4) and reportability assessment (b)(4).
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The investigation has determined that a non-reproducible, higher than expected troponin i result was obtained from a single patient sample using vitros troponin i es reagent lot 6385 on a vitros xt 7600 integrated system.A definitive assignable cause of the event could not be determined.Based on historical quality control results, a vitros tropi es lot 6385 performance issue is not a likely contributor to the event.Furthermore, continual tracking and trending of complaint data has not identified any signals to suggest there is a systemic quality issue with vitros tropi es reagent lot 6385.However, the customer does not process a control fluid with a troponin i concentration at, or below the url.Therefore, the performance of the vitros tropi es reagent lot 6385 at, or below the url concentration of 0.034 ng/ml (ug/l) cannot be determined and a reagent issue could not be entirely ruled out as contributing to the event.As no precision testing was performed on the vitro xt 7600 system, an instrument related issue cannot be entirely ruled out as a contributing factor of the event.However, there was no evidence of an instrument malfunction as historical qc results obtained on the instrument were within expectations.Pre-analytical sample processing could not be ruled out as a contributing factor as it is unknown if the customer was following the sample collection device manufacturer recommended centrifugation protocol.Improper pre-analytical sample handling could have contributed to the event.It is possible that cellular debris, due to poor sample preparation, was present in the affected sample, although this could not be confirmed.
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