UniCel DxH 800 Coulter Cellular Analysis System, REF numbers 629029, B24465, B24802, B68304, B66445, and B63322. Product

FDA device recall Z-1382-2019 · posted 2019-05-23 · Terminated

Recall details

Recalling firm

Beckman Coulter Inc.

Reason for recall

Complaints received of sporadic erroneously elevated platelet results without flags or system messages. Thrombocytopenia may go unrecognized.

Action taken

Urgent Medical Device Recall letters, dated July 30, 2018, were sent via email and postal mail on August 1, 2018 (for those customers not on their email notification system). On 05/22/19, second Urgent Medical Device (UMDC) Recall letters, and Important Safety Information notices, dated May 20, 2019 (replacing BEC UMDC letter dated July 30, 2018), were sent via mail and/or phone and/or e-mail informing customers perform the following actions: - Run samples on an instrument not subject to this recall to confirm the platelet results. - If an alternative instrument is not available, use the following quality control measures to aid in identification of discrepant platelet results: a) Perform manual scanning/estimate of platelets on a peripheral smear and compare with instrument results. Note that this method will identify samples with marked to moderate thrombocytopenia but may not identify smaller discrepancies. b) Repeat testing of samples in a workflow configuration may facilitate the identification of discrepancies. If an erroneous result is detected, review results from adjacent samples, i.e., those tested on the instrument both before and after the erroneous result. c) Additional instrument and/or LIS features including reference ranges, XM (exponentially-weighted moving average) and delta checks may be informative. d) Follow your laboratory's standard operating procedure to confirm unexpected results. - Ongoing investigation indicates that the probable root cause is the sweep flow disruption that may occur following the "Clear RBC Apertures" procedure. This potential root cause is currently under further investigation. Customers should discontinue using this procedure. If you suspect that your instrument has a clogged aperture that will not clear, discontinue use of the analyzer, contact Customer Support Center and request service. - Communicate to the ordering physicians the need to avoid patient treatment based solely on any single test resu

Root cause

Software Design Change

Status

Terminated

Product code

GKZ

Quantity affected

5,414 devices

Distribution

Worldwide Distribution - US Nationwide including Puerto Rico. There was government and military distribution. Foreign distribution was made to Andorra, Australia, Austria, Belgium, Canada, China, Croa

Date initiated

2018-07-30

Date posted

2019-05-23

Date terminated

2022-03-31

Location

Brea, CA

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