| Type of Product |
Medical Device |
| TGA Recall Reference |
RC-2018-RN-00926-1 |
| Product Name/Description |
Radiometer ABL800 blood gas analysers with software versions 6.14 through to Version 6.18. An in vitro diagnostic medical device (IVD).
ARTG Number: 228382
(Radiometer Pacific Pty Ltd - Instrument/analyser IVDs) |
| Recall Action Level |
Hospital |
| Recall Action Classification |
Class II |
| Recall Action Commencement Date |
9/07/2018 |
| Responsible Entity |
|
| Reason/Issue |
Radiometer has recently become aware that the ABL800 series analysers could potentially induce a patient mix-up when “Confirmation of Demographics” is enabled as part of the query to AQURE, Radiance, or a HIS LIS system. Please note that the default setting for this function is ‘disabled’.
The described error may potentially impact upon patient management as the physician may subject the patient to unnecessary treatment or erroneously withhold necessary treatment from the patient based upon the mixed-up of patient identification. In a worst-case scenario, where a critical parameter, such as K+ or pO2, is interrogated, based upon a false clinical diagnosis inferred from the erroneous measurement, a critically ill patient may be subjected to lack of critical treatment. |
| Recall Action |
Product Defect Correction |
| Recall Action Instructions |
Radiometer are currently working on a software correction. Once released, a Radiometer rep will contact users to schedule a visit to install the software upgrade.
In the interim, users are to confirm if "Confirmation of Demographics" is disabled on their analysers. If disabled, the issue will not be experienced.
If enabled, one of the two following counter-measures (CM) must be implemented:
CM #1: Disable “Confirmation of Demographics” as follows:
a. Logon to the analyser
b. Select “Menu” > “Utilities” > “Setup” > “General Setup” > “Communications” > “Automatic Data Request”
c. Remove the checkmark for “Confirm requested data”, if present
d. Select “Close”
Or
CM #2: If disabling the “Confirmation of Demographics” (CM #1) is not possible (e.g due to internal procedures), instruct all operators of the analyser(s) to not introduce a new sample when the menu for “Confirmation of Demographics” is being displayed.
This action has been superseeded by RC-2019-RN-00771-1. |
| Contact Information |
1800 247 254 - Simon Eldred, Blood Gas Product Manager |