MAUDE Adverse Event Report: SIEMENS HEALTHCARE DIAGNOSTICS PRODUCTS GMBH DADE INNOVIN

Model Number	DADE INNOVIN
Medical Device Problem Code	High Test Results (2457)
Health Effect - Clinical Code	No Known Impact Or Consequence To Patient (2692)
Date of Event	08/30/2019
Type of Reportable Event	Malfunction
Additional Manufacturer Narrative
The customer contacted a siemens customer care center (ccc).Siemens determined that pre-analytical issues (specific sample characteristics, blood collection, transportation, and/or sample processing/handling in the laboratory) potentially contributed to the discordant results.Siemens specialists were previously dispatched to the customer's site to evaluate and discuss pre-analytical handling conditions with the customer.The reagent is performing according to specifications.No further evaluation of this device is required.
Event or Problem Description
A discordant, falsely elevated prothrombin time (pt) result, a discordant, falsely elevated prothrombin time international normalized ratio (inr) result, and a discordant, falsely low prothrombin time percent (pt%) result were obtained on a patient sample on a sysmex cs-5100 system using dade innovin reagent.The same sample was repeated for pt and inr on the same system using dade innovin reagent, both resulting lower.The same sample was then repeated a third time for pt, inr, and pt% on the same system with dade innovin reagent.The pt and inr resulted lower and the pt% resulted higher.Using thromborel s reagent, the same sample was tested for pt, inr, and pt% on the same system.The pt and inr resulted lower and the pt% resulted higher.The same sample was then repeated again for pt, inr, and pt% on the same system with dade innovin reagent.The pt and inr resulted higher and the pt% resulted lower.The same sample was then tested for pt, inr, and pt% on an alternate sysmex cs-5100 system using dade innovin reagent.The pt and inr resulted lower and the pt% resulted higher.Using thromborel s reagent, the same sample was then tested for pt, inr, and pt% on the same alternate system.The pt and inr resulted lower and the pt% resulted higher.The same sample was then repeated again for pt, inr, and pt% on the same alternate system using dade innovin reagent.The pt and inr resulted higher and the pt% resulted lower.The same sample was then repeated again for pt, inr, and pt% on the same alternate system using thromborel s reagent.The pt and inr resulted lower and the pt% resulted higher.The last inr result obtained with dade innovin reagent was reported, as the correct result, to the physician(s).There are no reports of patient intervention or adverse health consequences due to the discordant, falsely elevated prothrombin time (pt) result, the discordant, falsely elevated prothrombin time international normalized ratio (inr) result, or the discordant, falsely low prothrombin time percent (pt%) result.

• Brand Name: DADE INNOVIN
• Common Device Name: DADE INNOVIN
• Manufacturer (Section D): SIEMENS HEALTHCARE DIAGNOSTICS PRODUCTS GMBH; emil-von-behring- str. 76; marburg, D-350 41; GM D-35041
• MDR Report Key: 9111269
• Report Number: 9610806-2019-00073
• Device Sequence Number: 19773674
• Product Code: GJS
• UDI-Device Identifier: 00842768003783
• UDI-Public: 00842768003783
• Combination Product (Y/N): N
• Initial Reporter Country: FR
• PMA/510(K) Number: K974343
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Reporter Type: Manufacturer
• Report Source: foreign,health professional,u
• Initial Reporter Occupation: Other Health Care Professional
• Type of Report: Initial
• Report Date (Section B): 09/24/2019

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: Health Professional
• Device Expiration Date: 07/19/2021
• Device Model Number: DADE INNOVIN
• Device Catalogue Number: 10445704
• Device Lot Number: 549733
• Was Device Available for Evaluation?: No
• Type of Report(Section G): Initial
• Initial Date Received by Manufacturer: 08/30/2019
• Initial Report FDA Received Date: 09/24/2019
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1
• Patient Age: 80 YR