Safety Alert for BACT/ALERT VIRTUO Systems

Safety alert

2018-07-12

2018-07-12

Hong Kong

DH

https://www.mdco.gov.hk/english/safety/recalls/recalls_20180712.html

Medical device safety alert: biomerieux bact/alert virtuo systems medical device manufacturer, biomerieux, has issued a medical device safety alert concerning its bact/alert virtuo systems [a) bact/alert virtuo a unit; b) bact/alert virtuo b unit; c) bact/alert virtuo a unit china; reference: a) 411660; b) 411661; c) 419947]. the manufacturer has identified an anomaly of the bact/alert virtuo instrument firmware version r2.0, which allows relocation of the four resident calibration standards so that field system engineers can service the associated cells p24 – p27, where the calibration standards typically reside. if the calibration standards are not returned to the designated locations, the anomaly may occur. following a reboot via the instrument’s small user interface screen, while patient or test bottles are loaded in cells p24 – p27, the following will occur: the unload date/time will be set to the current date/time, causing the bottle status to be set to “unload” even though the bottle remains in the instrument. the bottle will continue to process; however, in the event of a positive bottle in cells p24 – p27, no indication of a positive bottle will be observed by the user. neither the visual (flashing yellow light) nor audible alarm will occur. although the instrument does not provide alarm, the bottle result is transferred to the laboratory information system. two consecutive error conditions may also be observed for bottles in cells p24 – p27: an “anonymous bottle” alarm. a “duplicate bottle” alarm. according to the manufacturer, there is the potential for delayed culture bottle results due to the described anomaly if the user does not open the instrument door and manually unload the positive bottle so that the gram stain and subculture can be performed. a delay in the context of a patient with a bloodstream infection (positive culture) could delay diagnosis and/or life-saving medical interventions and the initiation of (or modification of existing empiric) antibiotics. additionally, extended clinical uncertainty during a reporting delay could subject a patient to unnecessary therapeutic and/or diagnostic procedures. in the interim, the users are advised to be vigilant when reviewing alarms for anonymous and/or duplicate bottles. if they become aware of a patient/test bottle loaded into cells p24 – p27, notify the local supplier. viewing or printing bottle reports will show accurate bottle results for positive and negative bottles, including patient/test bottles located in cells p24 – p27. according to the local supplier, the affected products are distributed in hong kong. if you are in possession of the products, please contact your supplier for necessary actions. posted on 12 july 2018.