Medical Device
Manufacturing
THE TRADE PAPER OF THE FACTORY FLOOR
Z-0738-2018Class I

Hematoxylin II, Ventana Part Number 790-22087, Roche GMMI 05277965001 in vitro diagnostic

Ventana Medical Systems Inc / initiated 2017-12-19 / Terminated / root cause: manufacturing process

Ventana Medical Systems Inc began a recall of Hematoxylin II, Ventana Part Number 790-22087, Roche GMMI 05277965001 in vitro diagnostic on . FDA classified it as Class I and gives the reason as "Increased reports of leaking and sticking reagent dispensers for horseradish peroxidase (HRP) dispensers (part of the iView, ultraView and OptiView detection kits, as well as CINtec PLUS Cytology Kit) and with...". As of , the recall status on record is Terminated, and MDM tags the root cause as manufacturing process.

Recall record

Recall number
Z-0738-2018
Classification
Class I
Status
Terminated
Initiated
Posted
Terminated
Recalling firm
Ventana Medical Systems Inc
Product
Hematoxylin II, Ventana Part Number 790-22087, Roche GMMI 05277965001 in vitro diagnostic
Product code
HYJ Hematoxylin
Reason for recall
Increased reports of leaking and sticking reagent dispensers for horseradish peroxidase (HRP) dispensers (part of the iView, ultraView and OptiView detection kits, as well as CINtec PLUS Cytology Kit) and with Hematoxylin II.
Root cause tag
manufacturing process
FDA root cause
Process control
Action
On Dec 19th all Roche affiliates (the direct consignees) worldwide were notified via Safety Board Notification (SBN) and subsequent Field Safety Notification (EX-US) and UMDC TD00090 (US) SBN and FSN revised Dec 20th due to 3 affected part numbers missed on original letter. The instructions are as follows: "Actions taken by Roche Diagnostics All affected product has been placed on hold. Ventana has reworked all product in its inventory and is in the process of manufacturing new lots for distribution and replacement of customer affected kits. Customers will be notified when corrected product is available. Actions to be taken by the customer/user Affected kits may continue to be used by customers until corrected product is available, however Ventana is mandating that the affected IHC detection kits (iView, ultraView, OptiView) must only be used in conjunction with same-slide controls. These controls must be appropriate for each assay and capable of detecting false negative results due to a complete or partial reagent dispense failure. CINtec PLUS Cytology does not have the capacity for same slide controls, so system-level controls should be maintained. ultraView SISH Detection is used for HER2 analysis, and employs internal positive controls; no external control is required. For assays that directly relate to clinical therapy decision making (e.g. ER/PR, HER2, ALK, etc.), it is additionally important to select a same slide positive control tissue with sufficient sensitivity to detect small decreases in intensity that may cause borderline positive cases to appear as negative (e.g. HER2 2+ vs. 1+). Although the use of same slide controls is considered optimal laboratory practice and strongly recommended by Ventana, customers may revert to standard run controls once non-impacted product is received. In order to reduce the risk of this issue impacting patient care, customers not using same slide controls as a standard practice should follow their
Quantity in commerce
71640 units
Distribution
Worldwide distribution, including US nationwide, Argentina, Australia, Hong Kong, Indonesia, Philippines, Brazil, Chile, Thailand, Korea, Malaysia, New Zealand, Ecuador, Mexico, Pakistan, Vietnam, Germany, Japan, India, Colombia, Singapore, Uruguay, Peru, Canada, Taiwan, China,
Product codes and lots
UDI 04015630972135, Lot Numbers: Y10759, Y17402, Y21312, Y13938, Y17403, Y22561

Enforcement reports

One row per recalled product line
FDA enforcement reports joined to recall event Z-0738-2018
Recall numberClassStatusVoluntary or mandatedReport dateClassified
Z-0729-2018Class ITerminatedVoluntary: Firm initiated
Z-0730-2018Class ITerminatedVoluntary: Firm initiated
Z-0731-2018Class ITerminatedVoluntary: Firm initiated
Z-0732-2018Class ITerminatedVoluntary: Firm initiated
Z-0733-2018Class ITerminatedVoluntary: Firm initiated
Z-0734-2018Class ITerminatedVoluntary: Firm initiated
Z-0735-2018Class ITerminatedVoluntary: Firm initiated
Z-0736-2018Class ITerminatedVoluntary: Firm initiated
Z-0737-2018Class ITerminatedVoluntary: Firm initiated
Z-0738-2018Class ITerminatedVoluntary: Firm initiated
Z-0739-2018Class ITerminatedVoluntary: Firm initiated
Z-0740-2018Class ITerminatedVoluntary: Firm initiated