MAUDE Adverse Event Report: IMMUCOR, INC. CAPTURE-R READY-ID EXTEND I; REAGENT RED BLOOD CELLS

Catalog Number	0006454
Medical Device Problem Code	False Negative Result (1225)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	05/13/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The immucor laboratory tested retention product on 30may2019, and found the retention product to be performing as expected.An immucor field service engineer (fse) visited the customer site on (b)(6) 2019 to assess the testing instrument, which performed as expected.All dp107 test well images resulted negative and were visually negative.The internal immucor record tracking number is (b)(4).
Event or Problem Description
On (b)(6) 2019, a customer site reported an unexpectedly negative antibody identification when using capture-r ready-id extend i when used on a galileo echo instrument.

• Brand Name: CAPTURE-R READY-ID EXTEND I
• Common Device Name: REAGENT RED BLOOD CELLS
• Manufacturer (Section D): IMMUCOR, INC.; 3130 gateway drive; norcross GA 30091 5625
• MDR Report Key: 8683370
• Report Number: 1034569-2019-00104
• Device Sequence Number: 2220816
• Product Code: KSZ
• UDI-Device Identifier: 10888234000662
• UDI-Public: 10888234000662
• Combination Product (Y/N): N
• Initial Reporter State: FL
• Initial Reporter Country: US
• PMA/510(K) Number: 102707/5030
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: health professional,user faci
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 06/10/2019

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: No Information
• Device Expiration Date: 06/25/2019
• Device Catalogue Number: 0006454
• Device Lot Number: DP107
• Was Device Available for Evaluation?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 05/13/2019
• Initial Report FDA Received Date: 06/10/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 39 YR