Instrumentation laboratory (il) was unable to conduct a thorough investigation.Multiple requests were made for data, however, the data files were not sent for evaluation.Based on the information provided from the customer the gem premier 4000 was performing to specification and the results provided from the gem premier 4000 were not questioned.The error occurred when the technician did not multiply the results by 0.01 (to obtain the fraction value for cohb and methb) when manually transcribing the results from the ticker tape to their laboratory information system.Based on the information provided, no remedial action is required.
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The customer reported that methb and cohb were analyzed on their gem premier 4000.Per local practice, their results were manually transcribed from ticker tape to their laboratory information system to convert to si units.The manual transcription requires that staff multiply the ticker tape results by 0.01 to obtain the fraction value for cohb and methb.However, the operator failed to do this and the patient was believed to have a methb of 80%.Based on their calculation error, the physician inappropriately administered methylene blue to the patient.Per the customer, the patient required "serious intervention" and had an extended hospital length of stay.Per the customer, the gem premier 4000 system operated to specification.The error was due to manual calculation errors when converting from % to si units.
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