MAUDE Adverse Event Report: IMMUCOR, INC. ANTI-FYB; BLOOD GROUPING REAGENT

Catalog Number	0007594
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	08/09/2017
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The immucor laboratory tested retention product on 10aug2017 which performed as expected.
Event or Problem Description
On (b)(6) 2017 it was determined that a customer report from (b)(6) 2017 of an unexpected positive result when using anti-fyb by manual test tube method, was reportable.The testing happened on (b)(6) 2017.

• Brand Name: ANTI-FYB
• Common Device Name: BLOOD GROUPING REAGENT
• Manufacturer (Section D): IMMUCOR, INC.; 3130 gateway drive; norcross GA 30091 5625
• MDR Report Key: 6940902
• Report Number: 1034569-2017-00274
• Device Sequence Number: 683631
• Product Code: KSZ
• UDI-Device Identifier: 10888234000808
• UDI-Public: 10888234000808
• Combination Product (Y/N): N
• Initial Reporter State: ND
• Initial Reporter Country: US
• PMA/510(K) Number: 102116
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: health professional,user faci
• Initial Reporter Occupation: Medical Technologist
• Type of Report: Initial
• Report Date (Section B): 10/11/2017

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: Medical Technologist
• Device Expiration Date: 06/21/2018
• Device Catalogue Number: 0007594
• Device Lot Number: 613030
• Was Device Available for Evaluation?: Yes
• Was the Report Sent to FDA?: No
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 08/09/2017
• Initial Report FDA Received Date: 10/11/2017
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1