Class 2 Device Recall BenchMark ULTRA

• Date Initiated by Firm: September 28, 2012
• Date Posted: August 06, 2013
• Recall Status: Terminated on February 24, 2016
• Recall Number: Z-0833-2013
• Recall Event ID: 64244
• Product Classification: Slide stainer, automated - Product Code KPA
• Product: VENTANA (a member of the Roche Group) BenchMark ULTRA; REF/MU 750-600; Research Use Only; ; ; Product Usage:; Research Use Only-The DISCOVERY ULTRA Advanced Staining System is intended to automatically stain histological or cytological specimens on microscope slides with specific inununohistochemistry or in situ hybridization reagents.
• Code Information: Cat#750-600; PN 05342716001; Serial #'s: 310724, 310735, 311187, 312055, 310373, 311052, 311171, 311953, 310750, 311266, 311267, 311564, 311565, 311596, 311304, 310481, 311924, 310607, 311627, 310527, 311436, 311742, 310132, 311432, 310034, 310408, 310687, 310697, 311343, 311958, 310728, 310778, 311991, 312070, 310471, 311326, 311952, 310103, 310777, 311446, 310924, 311303, 311528, 310490, 310913, 311529, 311494, 310139, 310281, 310465, 310275, 310617, 310665, 310716, 311853, 311871, 312137, 312101, 310240, 310237,310238, 311571, 311404, 310356, 310023, 312164, 312165, 310065, 310231, 310711, 310706, 310707, 310703, 311509, 310330, 310633, 311811, 311810, 310977, 311194, 311198, 310208, 310732, 310740, 310187, 311462, 311935, 310145, 311037, 310346, 310585, 310694, 310699, 310701, 310702, 310705, 310709, 310710, 310704, 311106, 311110, 311111, 311419, 311484, 311527, 310345, 311381, 311353, 310480, 311869, 311921, 311458, 310315, 310412, 311988, 310618, 310397, 310399, 311868, 311919, 312139, 312141, 312142, 311270, 310069, 311466, 311929, 310083, 310094, 310154, 311904, 310588, 312098, 312100, 310814, 311731, 311783, 311785, 312096, 312104, 312153, 310227, 310781, 310174, 311403, 311080, 311081, 311121, 311122, 311169, 311188, 311189, 311190, 311242, 311245, 311298, 311926, 310403, 310718, 311416, 311417, 312105, 312112, 310796, 310832, 310824, 311135, 311248, 312066, 310895, 310267, 310272, 311481, 311771, 311772, 310882, 311186, 311937, 310344, 311439, 311505, 310146, 310506, 311545, 310446, 310312, 311584, 312124, 310839, 311319, 311261, 310070, 310508, 311367, 311578, 311576, 311629, 311601, 311600, 311607, 311603, 311602, 311606, 311598, 311597, 311604, 311605, 311599, 311272, 312145, 312123, 310339, 310455, 310472, 310478, 310482, 311562, 311560, 311923, 311498, 311814, 311813, 311804, 310020, 310844, 311313, 311533, 310779, 311241, 311750, 310268, 310331, 311221, 311036, 311034, 311035, 310201, 310321, 310792, 312056, 311147, 311153, 311315, 311308, 310641, 310678, 310878, 310032, 311774, 311182, 310390, 311151, 311268, 311284, 311552, 310902, 311455, 310491, 311038, 312008, 310282, 310696, 311735, 310173, 310402, 311710, 312118, 311874, 310972, 311375, 311727, 312128, 312134, 310933, 310921, 311285, 310297, 310769, 311876, 310916, 311486, 310460, 310245, 310576, 311483, 312097, 312099, 312089, 312109, 311518, 311479, 311901, 312144, 312172, 311551, 310555, 310363, 311808, 310570, 311001, 310358, 310492, 311252, 311687, 311672, 311402, 310114, 310122, 310126, 311300, 310794, 311350, 311592, 310749, 310285, 311299, 310897, 311323, 310258, 310467, 310470, 311628, 310943, 310035, 310066, 310087, 310185, 310752, 310757, 311134, 312138, 310489, 311973, 311191, 310456, 310575, 310673, 310683, 310890, 310821, 312170, 312171, 312060, 312102, 312202, 310500, 310505, 311394, 311917, 311511, 311530, 310894, 312136, 311369, 311665, 312152, 310804, 311517, 311465, 310893, 310896, 311946, 311947, 310323, 310776, 310654, 310299, 310452, 311675, 310404, 310810, 310708, 310712, 311073, 311250, 310910, 311401, 311928, 310941, 310026, 310089, 310336, 310341, 311736, 311610, 311608, 311609, 311728, 310820, 311821, 310141, 310912, 311443, 311442, 311243, 311207, 310256, 310378, 310229, 312163, 312058, 310771, 311103, 310915, 310533, 310124, 311318, 310218, 310811, 311738, 310037, 310038, 310365, 310377, 311210, 312085, 312086, 312087, 311295, 312023, 311493, 311357, 310833, 310800, 311464, 311423, 311173, 311364, 310135, 310608, 310935, 311352, 311354, 311356, 310920, 310183, 310257, 310306, 310852, 311431, 310876, 311949, 311956, 310828, 310830, 310928, 310929, 310930, 310355, 310271, 311384, 312122, 310846, 311345, 310119, 310391, 310881, 310483, 310488, 311893, 312063, 310284, 311663, 312131, 310374, 310507, 310144, 310775, 311730, 311939, 310106, 310205, 310241, 310620, 310713, 310031, 310742, 311016, 311463, 310445, 312117, 310906, 311376, 311377, 311378, 311379, 311380, 310288, 311334, 311957, 311714, 310898, 311477, 310210, 310224, 311033, 312076, 312078, 312090, 310632, 312116, 310751, 310249, 311468, 310923, 310123, 311760, 310180, 311160, 310905, 310605, 310458, 311925, 310822, 311485, 311503, 311500, 311474, 310879, 312061, 310189, 310191, 312039, 312051, 312052, 312059, 312188, 311948, 311072, 310182, 310503, 310922, 311172, 311461, 311324, 311209, 310799, 310807, 310314, 310855, 312127, 310084, 310165, 311322, 311321, 310573, 310572, 311559, 310375, 310181, 310308, 312103, 312077, 312106, 312107, 312108, 310474, 310486, 312021, 312167, 312169, 311247, 310634, 310461, 312203, 310730, 310729, 311065, 311348, 311346, 311332, 310763, 312126, 310036, 310348, 310362, 311395, 311459, 311472, 311236, 311450, 311451, 310884, 311118, 311887, 311337, 311338, 310842, 310028, 310318, 310479, 311773, 311259, 311679, 312009, 312012, 310283, 310453, 310501, 310663, 310889, 310715, 311482, 311183, 311184, 310610, 311520, 311506, 310369, 310770, 310351, 310827, 310497, 311006, 311399, 311040, 311355, 312132, 312133, 311510, 310410, 312088, 311407, 310043, 310044, 310045, 310818, 310085, 311120, 311918, 311989, 311117, 310179, 311105, 311049, 312176, 310099, 311563, 310100, 310190, 311823, 310058, 310061, 310864, 311389, 310805, 310048, 311911, 311425, 311146, 310228, 310260, 311534, 310736, 310738, 310722, 311223, 310128, 310137, 310059, 312140, 311471, 311519, 310831, 310120, 311307, 310806, 311902, 310319, 311798, 311802, 312129, 312130, 311076, 311139, 311132, 311181, 311496, 311507, 312147, 312154, 310762, 310447, 311168, 310466, 311619, 311617, 310451, 311415, 311756, 312048, 311149, 310892, 311488, 311491, 311238, 311531, 311801, 311898, 311934, 310101, 310142, 311532, 311317, 311341, 310637, 311310, 311237, 310880, 311420, 312053, 311940, 311941, 311951, 311467, 310209, 310817, 311708, 310413, 311755, 310462, 310464, 311927, 311697, 310354, 312057, 311041, 311115, 311492, 311441, 310195, 310125, 310194, 310223, 310222, 310279, 310469, 310795, 310326, 311502, 311192, 311039, 311051, 311385, 310405, 311764, 310850, 311413, 310825, 310743, 310744, 310785, 310801, 310802, 310280, 310303, 311251, 311406, 311200, 311333, 310401, 311271, 310325, 311920, 310793, 310684, 310068, 311262, 311264, 310109, 311161, 311487, 312119, 311834, 311950, 311729, 311437, 311444, 312054, 311053, 311046, 311193, 310649, 310392, 311860, 310409, 312120, 312121, 311104, 311892, 310812, 310996, 310556, 311936, 310739, 311677, 312064, 312065, 312110, 312113, 310883, 311907, 311945, 310639, 311900, 310564, 311522, 311535, 311239, 311240, 310809, 311296, 311843, 311454, 311480, 310476, 312095, 311997, 311820, 310566, 311784, 311258, 310192, 310758, 311818, 311899, 311201, 311382, 310843, 310733, 310734, 311712, 311440, 311150, 310937, 310737, 310680, 310829, 311430, 310609, 310741, 311246, 311253, 311342, 310545, 310568, 311699, 311698, 310939, 310942, 310496, 310907, 311909, 310692, 310926, 310534, 311269, 310838, 310327, 311852, 312111, 310891, 310062, 310172, 310834, 310463, 310502, 310914, 311944, 311021, 310316, 311695, 311703, 311805, 311806, 311807, 311809, 312003,311005, 310885, 311752, 311751, 311732, 312150, 311942, 312026, 310676, 310225, 310353, 310473, 310475, 311508, 310717, 311089, 311148, 311138, 311140, 311141, 311320, 310454, 312143, 310593, 310591, 310657, 312081, 312125, 310226, 310611, 311349, 312151, 310322, 310064, 310748, 310216, 310494, 310495, 311029, 310217, 312016, 311775, 311777, 310443, 310597, 310603, 310602, 310606, 310360, 310130, 310131, 310133, 310143, 311178, 310138, 310140, 310276, 311792, 311504, 311501, 311499, 310411, 310621, 310690, 310727, 311249, 311288, 311400, 311418, 311457, 311470, 311696, 311694, 311693, 311309, 310040, 310681, 310823, 310798, 311056, 310416, 311408, 311344, 311906, 311624, 312017, 312033, 311943, 311048, 311409, 311495, 311758, 311093, 311447, 311885, 310367, 311489, 310352, 311975, 311977, 311339, 310376, 310379, 311653, 311199, 310385, 310414, 310485, 311260, 310244, 311365, 311366, 310324, 310033, 310304, 312010, 312011, 310918, 310919, 312007, 310156, 310819, 311765, 311490, 311351, 311063, 310899, 310903, 311022, 311025, 311088, 310660, 311274, 312146, 310027, 310909, 311922, 310134, 310041, 310232, 310613, 311497, 312062, 311575, 311740, 311970, 310538, 310644, 310873, 311822, 311536, 311980, 310188, 310574, 311383, 310925, 310958, 310960, 311030, 311019, 311179, 311180, 310121, 311087, 310877, 310449, 310450, 310487, 311515, 311427, 311516, 311452, 310219, 310239, 312203 All serial numbers in the market
• Recalling Firm/ Manufacturer: Ventana Medical Systems Inc; 1910 E Innovation Park Dr; Oro Valley AZ 85755-1962
• For Additional Information Contact: Robert D. Brooks; 520-877-7191
• Manufacturer Reason for Recall: Potiential for a waste fluid overflow condition to accur while running decontamination cycles on the BenchMark ULTRA automated staining platform or the DISCOVERY ULTRA automated staining platform. This type of overflow event can lead to migration of fluid across tubing and wiring within the instrument cabinet resulting in contact with electrical circuitry. This may create shorting conditions and u
• FDA Determined Cause: Device Design
• Action: The firm, Roche sent a "Technical Bulletin" and an letter dated October 3, 2012 to its customers. The letter and bulletin described the product, problem and actions to be taken. The customers were informed that Ventana is aggressively working on solutions to this issue. Until mitigations to the overflow condition are available for implementation; inform all personnel in your organization that work with the BenchMark ULTRA or DISCOVERY ULTRA instrument about the potential for fluid overflow to occur during decontamination cycles; follow the instructions provided in the letter to avoid the documented failure mode and follow the instructions provided in the technical bulletin. Contact your local support center with any questions or concerns or call 520-877-7191.
• Quantity in Commerce: 1735 instruments
• Distribution: Worldwide distribution: USA (nationwide) and country of: Germany.
• Total Product Life Cycle: TPLC Device Report

¹ A record in this database is created when a firm initiates a correction or removal action. The record is updated if the FDA identifies a violation and classifies the action as a recall, and it is updated for a final time when the recall is terminated. Learn more about medical device recalls.
² Per FDA policy, recall cause determinations are subject to modification up to the point of termination of the recall.
³ For details about termination of a recall see Code of Federal Regulations (CFR) Title 21 §7.55.